PBM Reform in 2026: How Pharmacy Benefit Manager Changes Affect PI Liens

James Wong — Founder & CEO, LienScripts | March 4, 2026 | 7 min read

Pharmacy benefit manager reform legislation in 2026 targets spread pricing, rebate transparency, and formulary manipulation. PI attorneys should understand how PBM changes affect medication access and why pharmacy liens through LienScripts operate outside the PBM system entirely.

Pharmacy benefit manager (PBM) reform legislation advancing in 2026 targets the practices of the three largest PBMs that control approximately 80% of prescription drug adjudication in the United States. These reforms address spread pricing, rebate pass-through requirements, and formulary transparency. For personal injury attorneys, PBM reform matters because PBM practices directly affect which medications injured plaintiffs can access through insurance and how much those medications cost at the pharmacy counter. Pharmacy lien services through LienScripts operate entirely outside the PBM system, providing a direct pathway to medication access that is unaffected by PBM practices or reform.

• PBM reform in 2026 targets spread pricing, rebate transparency, and formulary manipulation by the three largest pharmacy benefit managers
• PBM formulary decisions determine which medications insurers cover and at what cost to patients
• LienScripts pharmacy liens bypass the PBM system entirely, dispensing medications without insurance adjudication
• PBM-driven step therapy and formulary restrictions frequently delay appropriate injury medications
• LienScripts generates a MERIT (Medication Evaluation & Rationale for Injury Treatment) report for every case, providing pharmacist-signed documentation for demand packages

What PBMs Do and Why Reform Is Happening

Pharmacy benefit managers sit between health insurers, pharmacies, and drug manufacturers. They negotiate drug prices, determine formulary placement, process prescription claims, and set reimbursement rates for pharmacies. The three largest PBMs, CVS Caremark, Express Scripts, and OptumRx, collectively manage prescription benefits for over 200 million Americans.

Reform legislation targets several PBM practices that critics argue increase costs and restrict patient access to medications:

Spread pricing. PBMs charge health plans one amount for a drug while reimbursing pharmacies a lower amount, keeping the difference. Reform legislation requires PBMs to pass through the full negotiated price.

Rebate retention. Drug manufacturers pay rebates to PBMs for formulary placement. Reform measures require PBMs to pass a larger percentage of rebates to the health plan or directly to patients at the point of sale.

Formulary manipulation. PBMs may prefer higher-rebate medications over clinically appropriate alternatives. Reform requires greater transparency in formulary decisions.

According to James Wong, PharmD, founder of LienScripts, "PBM reform is overdue, but personal injury patients cannot wait for systemic change. The pharmacy lien removes the PBM from the equation entirely. The prescriber decides the medication, the pharmacy fills it, and the lien covers the cost from the settlement."

How PBM Practices Harm PI Patients

Personal injury plaintiffs interact with the PBM system whenever they attempt to fill prescriptions through their health insurance. Several PBM practices create specific problems for injured patients.

Formulary Restrictions

PBMs determine which medications are on the preferred formulary. When a prescriber writes for a non-preferred medication, the patient faces higher copays, prior authorization requirements, or outright denial. For personal injury patients who need specific medications based on their injuries rather than formulary economics, this creates barriers to appropriate care.

Step Therapy Requirements

PBMs often require patients to try cheaper medications first before approving the medication the prescriber actually ordered. For a patient with acute injury pain, being required to fail on a first-line medication before accessing the prescribed treatment adds weeks of inadequate pain control.

Pharmacy Steering

Some PBMs steer patients to affiliated mail-order or retail pharmacies, limiting which pharmacies can fill prescriptions at preferred rates. This can disrupt established pharmacy relationships and create logistical barriers for patients who are already dealing with injury-related limitations.

Reimbursement Cuts to Pharmacies

Low PBM reimbursement rates have forced independent pharmacies to close, reducing access points for patients. In rural and underserved areas, pharmacy closures mean injured patients must travel farther to obtain medications.

Why Pharmacy Liens Bypass the PBM System

The LienScripts pharmacy lien model does not involve health insurance, which means PBMs play no role in the medication access process. When a personal injury patient enrolls in the LienScripts program:

• The prescriber writes the prescription based on clinical need
• The pharmacy fills the prescription without insurance adjudication
• No PBM formulary, step therapy, or prior authorization applies
• The patient receives the medication at zero upfront cost
• The lien attaches to the future settlement proceeds

This structure means that PBM reform, while beneficial for the general population, has no direct impact on the pharmacy lien process. Attorneys who connect clients with LienScripts insulate those clients from PBM-related access problems regardless of how reform progresses.

For attorneys managing multiple pharmacy lien cases, the PBM-independent model simplifies case management because every prescription follows the same direct-access pathway.

What Attorneys Should Know About PBM Reform

Reform Timeline Is Uncertain

Federal PBM reform bills have advanced through committee hearings but face industry opposition. State-level reforms vary significantly. Attorneys should not rely on PBM reform to solve medication access problems for current clients.

Clients May Still Face PBM Issues for Non-Injury Medications

Personal injury patients often take medications for pre-existing conditions alongside injury-related prescriptions. PBM issues may affect their non-injury medications even when the lien covers injury-related drugs. Attorneys should be aware that clients may still struggle with PBM-related access for their other prescriptions.

PBM Practices Create Documentable Treatment Barriers

When a client experienced PBM-driven formulary denials, step therapy delays, or pharmacy steering before enrolling in the lien program, those experiences are documentable treatment barriers. The MERIT report from LienScripts captures the medication timeline and can be compared against the original prescription dates to show gaps caused by insurance and PBM obstacles.

Use Pharmacy Records in Demand Packages

Include documentation of PBM-related barriers in the demand package narrative. Insurance adjusters and opposing counsel understand that PBM restrictions create real obstacles, and documenting those obstacles strengthens the treatment barrier portion of the claim.

The Practical Takeaway

PBM reform in 2026 may eventually improve the medication access landscape for all patients. But personal injury plaintiffs need medications now, during active cases with treatment deadlines and pain management needs that cannot wait for legislative timelines. The pharmacy lien through LienScripts provides immediate, PBM-free medication access that protects clients from formulary restrictions, step therapy delays, and pharmacy steering practices that reform has not yet resolved.