It is common for pharmacy benefit managers (PBMs) to update the terms and conditions of their provider manuals ahead of a new year or throughout the year. Although new editions of these provider manuals do not always contain updates that have significant impact on pharmacy participation, there are several updates in the 2026 editions of major PBMs’ provider manuals that pharmacies should be aware of.
Medicare Drug Price Negotiation Program
One major PBM’s 2026 provider manual now includes an additional section regarding pricing for Medicare drug products that implements the Inflation Reduction Act’s (IRA) Medicare Drug Price Negotiation Program (which requires CMS to negotiate prices for high-cost, single-source drugs). This places additional operational and administrative requirements on participating providers in order to receive reimbursements for services rendered to Part D patients, including the following:
- Enrollment in CMS’s Medicare Transaction Facilitator Data Module (MTF DM) or its successors;
- Certification to CMS that the enrollment information provided is accurate and up to date; and
- Attestation to the major PBM confirming the accuracy of the enrollment information provided,
As a result of the above, the PBM’s terms have also been updated to limit the reimbursement received by pharmacies for certain drugs to maximum fair price dispensing fees less the copayment owed by the patient, if applicable, to ensure the savings intended by this program are passed directly to patients.
Previously Prohibited Coupons
Prior to 2026, one major PBM prohibited the application of coupons from several identified programs. However, the same PBM’s provider manual has revised the list of programs to allow pharmacies to use and apply coupons from certain programs that were previously prohibited.
Pharmacies that process coupons and similar secondary claims, should be sure to confirm the eligibility of coupons and patient payment programs prior to submitting claims to any PBM.
Third-Party Use of Pharmacy NPIs
Similarly, a major PBM’s 2026 provider manual also relaxes previous requirements regarding the use of providers’ NPIs by third parties. While the use of a pharmacy’s NPI by a third party was previously prohibited (absent express approval from the relevant PBM), pharmacies may now allow third parties to submit claims to the PBM on their behalf, so long as the PBM is notified and the third parties are confirmed to be operating in compliance with applicable federal and state laws.
While this opens the door for pharmacies to participate in hub arrangements, pharmacies should confirm that such arrangements are in compliance with applicable federal and state laws.
Obligations to Maintain Audit Documentation
In addition to the above, several 2026 PBM provider manuals continue to require their providers to maintain the following documentation:
- Trackable and verifiable proof of copayment amounts (i.e. copies of the front and back of checks, card receipts, or bank cash deposits and/or evidence of coordination of benefits involving coupons or other payers); and
- Front and back of original prescription orders.
It’s important to note that the documentation requirements themselves are not new. On the contrary, these are the same requirements that may have been previously identified. However, as of 2026, pharmacies now have an ongoing obligation to maintain such documentation, regardless of whether that documentation becomes necessary to resolve discrepancies identified by an audit.
Therapeutic Class Restriction
Beginning in 2026, another major PBM’s provider manual will include a new restriction that may significantly impact pharmacies that specialize in particular therapeutic areas. The new provision will require that network pharmacy providers have no more than 25% of their total claim submissions and/or amount paid attributed to a single therapeutic class, unless they have obtained specific prior approval from the PBM.
In effect, this restriction means that pharmacies participating in this PBM’s networks will not be permitted to specialize or focus in one specific therapeutic area without obtaining prior approval. This is likely to have a significant impact on any pharmacy whose practice concentrates in a particular therapeutic class (including but not limited to oncology, HIV/AIDS, rare disease, and other specialty areas), which by their nature involve dispensing large quantities of medications within a single therapeutic class.
As of the date of this alert, the PBM that implemented this restriction has suggested, though not clearly, that such threshold limitation primarily applies to pharmacies seeking admission into the network. Nevertheless, pharmacies should be aware of any dispensing limitations and/or thresholds across all PBMs to maintain compliance.
How Frier Levitt Can Help
Updates to PBM provider manuals can have significant implications for pharmacy operations, reimbursement, network participation, audit exposure, and compliance obligations. Pharmacies should carefully review new provider manual provisions to understand how changes may affect their day-to-day operations and contractual responsibilities. Failure to comply with updated requirements can lead to audit findings, recoupment demands, reimbursement disputes, network restrictions, or even termination from a PBM network.
Frier Levitt regularly advises pharmacies nationwide on PBM contracting, provider manual compliance, audit defense, network participation issues, reimbursement disputes, and regulatory compliance matters. Our attorneys assist pharmacies in evaluating new PBM requirements, responding to adverse actions, challenging inappropriate audit findings, and negotiating favorable resolutions with PBMs. If your pharmacy has questions regarding recent provider manual updates or their potential impact on your business, contact Frier Levitt to speak with an attorney.
