Medicare's New PBM Rule Has No Row in Its Own Cost Table
CMS filed a 265-page proposed rule on Friday that spends 102 pages rewriting how pharmacy benefit managers get paid in Part D from 2028, then books no dollars and no paperwork hours against any of it. The ten-year impact table has two rows for three provisions, the burden table has 46,291 hours all sitting on Medicare Advantage directories, and that is how a rule creating twelve new sections of part 423 gets declared de minimis at $6 million.
Three contacts sit at the top of the rule CMS filed on Friday afternoon.
Kristy Nishimoto, with a phone number, for the dual eligible copay provision. James Clark, with a phone number, for the provider directory provisions.
For the third one, no name and no number. Just a mailbox: PartDPBM@cms.hhs.gov.
That asymmetry runs the length of the document.
CMS-4214-P went on public inspection at 4:15pm Eastern on Friday, a special filing of 265 pages, and it hits the Federal Register tomorrow morning. It implements three sections of the Consolidated Appropriations Act, 2026.
Its ten-year impact table carries two rows.
The one with no row is section 6224, the pharmacy benefit manager provision, and it takes 102 pages of preamble to explain, more than the other two provisions put together (chart below).
"What does the PBM half of this rule cost anybody?"
CMS does not answer. Not in Table I.1, not in Table IV.1, not in the accounting statement, and not in the collection of information requirements.
The half that got counted
We ran the other two provisions here on Saturday, the directory rules at 7am and the $1.337 billion dual copay transfer at noon. Both got a number, and the directory half got one worked to the half-hour.
Table III.11 is where that work lives. It totals 5,282 responses and 46,291 hours at $6,025,071 in the first year and $1,608,453 a year after that, and every one of its thirteen rows cites a section of 42 CFR part 422:
- § 422.2 and § 422.123(b)(4), at 1.5 and 3 hours per MA organization contract across 708 contracts.
- § 422.123(d)(1)-(4), the accuracy analysis, split into three respondent bands: 113 parent organizations at 13 hours, 38 at 20 hours, 12 at 30 hours.
- § 422.123(d)(5), the accuracy report, in the same three bands at 8, 12 and 18 hours.
- § 422.124, the cost sharing protections, including a 40-hour one-time system build at $142.40 an hour for a software developer.
Not one row cites part 423.
CMS knows how many MA organizations there are, how many plans each parent runs, and what a business operations specialist costs per hour. On the PBM side it names no respondent universe at all.
The rest of this brief is for subscribers.
The impact tables, the code-level detail, and the rest of the analysis sit past this line.
$50 a month, or $500 a year.
Already a subscriber? Sign in