State lawmakers are opening a new front in their battle with pharmacy benefit managers, advancing legislation that would bar the powerful companies that manage prescription drug benefits from simultaneously owning retail or mail-order licenses at chains like CVS Pharmacy and Express Scripts.

The push gained momentum in Tennessee last week when a House committee advanced a bill modeled after a first-in-the nation Arkansas law. More than half a dozen states have considered similar legislation over the past year, a sign of how the debate over pharmacy benefit managers is shifting.

After years of passing narrower laws aimed at curbing specific PBM practices — spread pricing, pharmacy audits, reimbursement formulas — some lawmakers are beginning to question whether incremental reforms can work as long as PBMs remain vertically integrated with insurers and pharmacy chains.

“If we ever want to get back to a health care system where the patient and the physician are in control in the pharmacy, you can’t have this monopolistic enterprise,” Tennessee Rep. Rick Scarbrough, a Republican, said during a hearing on his bill.

The six largest PBMs manage nearly 95% of all prescriptions filled in the United States, giving them the power to design health plans, determine which drugs are covered and decide how much pharmacies get reimbursed.

Supporters of ownership bans say it creates unavoidable conflicts of interest, allowing companies to steer patients to affiliated pharmacies, control pricing information and retain rebates that might otherwise reduce drug costs. They also say piecemeal regulation can’t adequately check that concentration of influence, and that earlier state laws that were aimed at curbing specific practices have often had limited impact.

In Pennsylvania, for example, a 2024 law intended to prohibit some forms of steering and preferential reimbursement applies only to certain commercial insurance plans licensed in the state, leaving most Medicaid, Medicare and self-insured plans outside its scope, said Rob Frankil, executive director of the Philadelphia Association of Retail Druggists, a community pharmacy trade organization.

“It’s very narrow,” Frankil said. “We need to layer on new legislation, or make that legislation more robust and meaningful.”

Independent pharmacy advocates say PBMs that own pharmacies can also favor their own stores through network design or reimbursement rates, making it difficult for unaffiliated pharmacies to compete.

Opponents of tighter restrictions counter that forcing companies to separate those businesses could reduce efficiency and lead to pharmacy closures in some markets.

Many of the more restrictive proposals are modeled after a 2025 Arkansas law that prohibits PBMs and insurers from owning pharmacies, though that measure has been tied up in federal court.

Proposals in Indiana, New Jersey and Texas failed to advance, while bills in Arizona, New York and Vermont remain technically active but appear stalled. Lawmakers in Pennsylvania have also announced plans to introduce legislation that would include a similar ownership restriction, and an Oklahoma bill is advancing in the House.

Several of the bills have drawn broad bipartisan support.

The Tennessee legislation has backing from the Republican leaders of both chambers, as well as some prominent Democrats. Louisiana’s proposal last year was a top priority of Republican Gov. Jeff Landry, but it died in the Senate. And a coalition of 39 attorneys general from both red and blue states urged Congress last year to adopt similar restrictions at the federal level.

Federal lawmakers have also introduced legislation with bipartisan sponsorship that would restrict PBM ownership of pharmacies, signaling a growing national effort to address conflicts of interest. If passed, such federal legislation could preempt commerce clause concerns and give states a clearer framework for regulating PBMs, observers said.

Some supporters say it remains unclear whether any of the state measures will ultimately be enacted or survive expected legal challenges, due in part to fierce opposition from chain pharmacies and their parent companies, which say the proposals are anti-competitive.

“This bill is very dangerous for patients’ health and will not lower drug costs for anyone,” Greg Lopes, a spokesman for the PBM trade group the Pharmaceutical Care Management Association, said in a statement responding to the Tennessee legislation.

“The bill does not improve access to prescription benefits, nor does it provide any safeguards for patients who would lose access to their drugs as a result of the legislation causing mass pharmacy closures. By shutting down pharmacies, the bill would create barriers to access, raise drug costs and make people sicker.”

Industry advocates point to new research suggesting that policies forcing PBMs to divest pharmacies could raise national drug spending by roughly $32 billion and lead to about 44,000 additional hospitalizations, risks they say stem from reduced medication adherence if pharmacy access is disrupted.

CVS Health — which controls roughly a quarter of the U.S. retail pharmacy market — has mounted an aggressive campaign in Tennessee, spending $1.4 million on television ads and sending customers text messages warning that the company could close all 134 of its stores in the state if the measure passes.

“It’s bad for Tennessee, for the more than 1.5 million patients we serve and for the more than 2,000 colleagues who will lose good paying jobs,” CVS Health spokeswoman Amy Thibault said in a statement.

The company deployed the same tactic in Louisiana last year.

Lawmakers abruptly shelved the ownership ban in the waning hours of the legislative session in favor of a less aggressive transparency measure.

Attorney General Liz Murrill responded by suing CVS, claiming it had illegally used contact information obtained under the guise of prescription and health notifications. The state ultimately filed three lawsuits against the company last year and announced a $45 million settlement with CVS in February.

CVS said it would have to close its 23 pharmacies in Arkansas if the law there takes effect.

CVS Health and other PBM operators, including Cigna’s Express Scripts, have filed federal lawsuits challenging the Arkansas law, arguing it violates constitutional protections.

Industry groups are expected to challenge similar laws wherever they pass, advocates say, a strategy that could delay implementation while courts determine whether states have the authority to regulate PBM ownership structures.

Advocates for independent pharmacies say lawmakers are increasingly willing to consider structural changes after years of passing PBM regulations that failed to alter industry behavior.

Joel Kurzman, director of state government affairs at the National Community Pharmacists Association, said that in some states audits have found PBMs ignoring key provisions of state law.

“They’ll pay their fines without admitting wrongdoing,” Kurzman said. “It becomes a cost of doing business, but the behavior doesn’t change.”

Independent pharmacies are also facing sustained closures. In 2023, more than 300 shuttered — nearly one per day. And over the past decade roughly 1 in 3 U.S. retail pharmacies closed, illuminating the pressures on neighborhood pharmacies.

Not every bill is introduced with immediate passage in mind.

In some states, lawmakers use the proposals to put PBM practices on the record and build momentum for future legislation, Kurzman said.

“For years, independent pharmacies have been playing defense,” he said. “This is one of the first times we’re trying to put PBMs on the defensive.”