4 of the Latest Trends in Prescription Drug Legislation

4 of the Latest Trends in Prescription Drug Legislation

On lawmakers' radar: the 340B program, pricing transparency, pharmacy benefit managers and consumer costs.

NCSL tracking shows that 38 states and Washington, D.C., have introduced over 300 prescription drug bills this year. (Charles Wollertz/Getty Images)

Last year, state legislators across the nation introduced at least 875 prescription drug-related bills.

Many covered key issues, such as the federal 340B Drug Pricing Program, consumer costs and the business practices of pharmacy benefit managers, or PBMs. Early data from NCSL's Prescription Drug Legislation Database shows 38 states and Washington, D.C., have introduced over 300 bills in 2026, with several revisiting these same topics.

Here are four of the top legislative trends.

1. Reforming the 340B Drug Pricing Program

The federal 340B Drug Pricing Program is designed to give safety net facilities-the public hospitals and clinics serving low-income patients-access to manufacturer discounts on outpatient drugs. Increased program spending is drawing the attention of state lawmakers, with 19 states enacting 22 bills related to the 340B program in 2025. At least 13 states are considering actions in 2026.

Legislative actions include:

Establishing pharmacy protections. Ensuring patients have access to 340B pharmacies was a prominent 2025 legislative trend, and some states set antidiscrimination standards to protect participating pharmacies.

For example, Maine and Oklahoma now require that pharmacies participating in 340B receive the same reimbursement amounts as nonparticipating pharmacies. In addition to network protections, Arizona prohibits third parties from imposing additional fees, assessments or clawbacks on 340B pharmacies. Rhode Island banned pharmacy network exclusion based on 340B participation.

For 2026, lawmakers in some states are discussing protections for 340B entities. Introduced bills include references to preserving a patient's choice to get medications at a 340B-contracted pharmacy or directly from the participating 340B entity, or requiring manufacturers not to limit shipments of drugs to 340B pharmacies and covered entities.

Prohibiting claims-data requirements to receive rebates. Participating 340B pharmacies may dispense medicines to patients and extract savings from either 340B discounts or Medicaid rebates, but not both. To demonstrate program compliance, 340B pharmacies must report certain cost and pricing data to the Centers for Medicare & Medicaid Services through state agencies. CMS then conveys that information to manufacturers for Medicaid rebate disbursement, and to ensure duplicate discounts do not occur.

Notably, the information CMS sends manufacturers is without claims-level identifiers. Several manufacturers now require 340B entities to report claims data before providing 340B discounts.

To ensure 340B entities are provided up-front discounts, supply chain entities in New Mexico and South Dakota may no longer require 340B claims or utilization data before providing reimbursement. Bills in at least 11 states so far this year propose similar restrictions.

2. Improving Transparency and Oversight

States have long sought to establish or enhance transparency requirements to ensure that prescription drug supply chain actors report certain cost and pricing information to state agencies, consumers or other entities. Several states are broadening the scope of their transparency initiatives and shifting their focus to address a wider range of supply chain activities.

Actions include:

Improving 340B administration. As concerns over increased 340B program spending grow, many lawmakers want greater clarity about how those funds are being used. For example, Minnesota was the first state to require entities participating in the program to report both the total savings they generate from 340B drug purchases and how those savings are used to benefit patient care. Idaho enacted similar reporting requirements in 2025, and so far this year at least five states are considering bills seeking more insight into 340B program activities.

Adding licensure and reporting requirements. Last session, policymakers in Oregon and North Carolina took a different direction by requiring pharmacy service administration organizations-which negotiate contracts with pharmacy benefit managers on behalf of independent pharmacies-to disclose their ownership information to state agencies as part of new licensure procedures. At least 11 states and Puerto Rico are considering transparency bills affecting not only PSAOs, but also a variety of supply chain actors.

3. Reforming Pharmacy Benefit Managers

For over a decade, lawmakers have devoted significant attention to the business practices of pharmacy benefit managers, or PBMs. Last year, 63 bills passed in 18 states. Many legislatures sought to reform contractual arrangements in the industry by adding new requirements and standards.

State actions include:

Imposing fiduciary duty requirements. The federal Employee Retirement Income Security Act (ERISA), enacted in 1974, requires health plans to act responsibly and prioritize the interests of those they serve, also known as a fiduciary duty. Although ERISA sets standards for health plans, a U.S. Supreme Court decision determined that the law does not apply to PBMs, giving state lawmakers regulatory authority over PBM practices.

Several states now require that PBMs perform a fiduciary duty to health plans and their members. In 2025, efforts in Connecticut and Indiana applied fiduciary, or duty-of-care, requirements to PBMs, and at least three states are considering similar requirements this year.

Addressing PBM compensation. More than a dozen states explicitly limit spread pricing contracts, in which PBMs retain the difference between what they reimburse pharmacies and what insurers pay for drug claims. For example, eight states tackled spread pricing in 2025, and many are looking at revising rebate-based compensation structures in 2026.

After legislation passed in 2025, Colorado PBMs may earn income only from a flat-dollar service fee. This year, several states are considering bills requiring PBMs to shift to fee-based contracts. Virginia enacted 2025 legislation to establish a single PBM as the state administrator of pharmacy benefits, and lawmakers there are considering another bill requiring the PBM to use a pass-through pricing model and pass all rebates to the health plan.

4. Lowering Consumers' Out-of-Pocket Costs

Specialty medications can significantly enhance a person's health, often at a high price. A recent KFF poll found that one-third of adults say prescription drug costs are unaffordable, and to save money they may consider other options, such as not filling a prescription.

Legislative action includes:

Modifying utilization management practices. To control spending, Medicaid, Medicare, private insurance plans and PBMs employ utilization management practices-criteria used to evaluate the necessity of medications and health care services. Such policies include copay accumulators (limiting how much third-party assistance counts toward out-of-pocket maximums); step therapy (requiring patients to try less expensive treatments before moving to costlier ones); and prior authorization (requiring approval before certain drugs are covered). Revising these protocols is one strategy lawmakers are pursuing to lower the amount people pay. In 2025, lawmakers introduced 44 bills in 19 states addressing these policies, and 22 states are already working to improve patient affordability while ensuring continued access to essential treatments.

Evaluating GLP-1 coverage. Although insurers commonly cover the cost of GLP-1 medications when prescribed for diabetes, they less frequently cover them when prescribed for obesity. As the use of GLP-1s has increased in recent years, state lawmakers are grappling with how to expand coverage and access to these treatments.

Florida began providing GLP-1 medications to state employees as part of a 2020 pilot program, and efforts are underway this year to make the coverage a permanent feature of health plan offerings. State employees in Illinois also now have GLP-1 coverage, and state employee or Medicaid coverage requirements are under consideration in at least 11 other states in 2026.

What's Next?

Lawmakers continue to advance a wide range of approaches designed to enhance prescription drug access and affordability for both states and consumers. Even as the legislative landscape evolves, initiatives including PBM and 340B reform are likely to be enacted this year. As legislative sessions progress, the impact of these policy changes will become clearer, shaping the future landscape of prescription drug coverage and affordability across the states.

Colleen Becker is a project manager in NCSL's Health Program.