When Health Plans Block Chronic Medications: A Growing Crisis—and What’s Changing in 2025

The Problem: Forced Detours for Critical Rx

More than half of insured Americans reported being denied coverage for chronic or rare disease medications—and nearly half were referred to external programs to obtain them. These detours led to delays of weeks to months, causing physical and mental health deterioration, additional medical visits, and even ER trips.

What’s Shifting This Year: Transparency, Reform, and Federal Action

1. FTC Crackdown Boosts Transparency in PBM Practices

Regulatory pressure on pharmacy benefit managers (PBMs) has intensified significantly. The Biden administration and federal agencies like the FTC and CMS are driving tougher transparency rules around spread pricing, rebate disclosures, and PBM behavior. Spread pricing is a common but controversial practice used by pharmacy benefit managers (PBMs). It refers to the difference between what a PBM charges a health plan for a prescription drug and what it pays the pharmacy to dispense that drug. The PBM keeps the “spread” as profit. These reforms are reshaping industry norms.
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2. Bipartisan Legislation Targets PBM Accountability

In mid-2025, the Pharmacy Benefit Manager Reform Act of 2025 was introduced. With broad support—including from the American Medical Association—the bill would ban spread pricing, decouple PBM compensation from drug prices, require fair pharmacy reimbursement, and greatly enhance transparency and enforcement.
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3. Proactive State-Level Reform Takes Shape

States are setting a strong pace. Many—including Massachusetts, Mississippi, and others—are passing laws requiring PBM licensing, rebate disclosure, and prohibitions on spread pricing. These state efforts are setting new standards for drug cost and access nationwide.
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Presidential Influence: How the New Administration Is Steering Reform

• Federal Momentum Builds: The Biden administration’s stance on transparency aligns with enforcement via FTC actions and CMS rule-making. While a sweeping funding package stalled some reforms, federal agencies are clear in pushing forward PBM oversight.
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• State Impact Matters: With federal legislation lagging, state initiatives—backed by advocacy and bipartisan support—play a critical role in achieving real instead of theoretical change.

Why It Matters—And What You Can Do Now

Take action now with the Healthcare Pharmacy Consortium. If you are a Post‑Acute operator, you don’t have to go it alone—this exclusive, members‑only initiative empowers you to benchmark and optimize your pharmacy spend with no obligations. Through the Consortium, participants access group purchasing power that delivers 20–50% in drug cost savings, while preserving the flexibility to negotiate with your current PBM or simply confirm your pricing position. For many, collaborating with a pharmacy consultant alongside the Consortium has yielded even greater value—all in a transparent, supportive environment designed to move pharmacy strategy forward. Join the broader movement toward smarter, stronger benefit solutions—and let the Healthcare Pharmacy Consortium be your partner in real change. Contact the consortium today to learn more.

 Now More Than Ever:

• Health plan sponsors and benefit leaders should monitor PBM contracts closely, emphasizing transparency and rebate flow.
• Consider state-specific regulations affecting your plans, especially if spanning multiple jurisdictions.
• Support and advocate for PBM reform through associations and policy channels.

Key Sources

1. Coverage denials and patient harm, as reported by BenefitsPRO: delays from external copay programs harming both physical and mental health.
   washingtonpost.com+10Wikipedia+10American Medical Association+10American Medical Association+1Intercept HealthPharmacy Times
2. Federal push for PBM transparency, via CMS, FTC, and Biden administration enforcement.
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3. Pharmacy Benefit Manager Reform Act of 2025, backed by AMA and addressing spread pricing, reimbursement, and transparency.
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