News Archive

"Assembly Bill A9729, effective as of May 22, 2026. is fundamentally a pharmacy practice and licensure law, not a benefits mandate.... Although it does not directly regulate employer health plans, it substantively affects the pharmacy and PBM environment that plans operate within."  MORE >>

"In 2025, nearly half of all large employers covered GLP-1 medications, but costs are becoming prohibitive and more employers cut back on coverage in 2026 and are talking about more cuts in 2027. While the GLP-1 pills are priced essentially the same as injectables, trials show they are less effective for weight loss, and it's possible that some employers may not put them on their list of covered drugs."  MORE >>

"Although not intended, the new federal programs have the potential to introduce both direct and indirect medical and drug costs to group-based plan sponsors, beginning as early as July 2026. Further, if the BALANCE Model launches as planned in 2028, group-based plan sponsors will face a decision. They can participate in the program to offer GLP-1s to retirees on a group basis and take on the associated costs or they can direct retirees to the individual Medicare marketplace to obtain GLP-1s and other Medicare medical, drug, and ancillary benefits."  MORE >>

"Although this is the fourth cycle of negotiations between Medicare and drug companies, this is CMS's first time engaging in the rulemaking process, as the IRA authorized CMS to administer the MDPNP through guidance for the first three years of the program.... [This article describes] how CMS's procedural transition from guidance to rulemaking may impact the functioning of the program. [The authors also] describe and analyze the substantive policies that CMS added or changed from previous negotiation cycles."  MORE >>

"Senate Bill 1545 ... would prohibit PBMs from owning or holding permits for the retail sale of prescription drugs in Arizona beginning January 1, 2027. While the bill remains in the early stages of the legislative process, it has already attracted attention because it goes beyond traditional PBM reform measures and directly targets vertical integration and follows a growing trend of similar bills."  MORE >>

"CMS is seeking input on key provisions of the Medicare Part D PBM reforms enacted earlier this year, including the upcoming 'delinking' requirements and new PBM data reporting obligations scheduled to take effect in 2028.... CMS is now seeking stakeholder input on several foundational questions ... The answers to these questions could have a substantial impact on how PBMs structure contracts, how affiliated entities are treated and how revenue streams are evaluated in the future."  MORE >>

"Express Scripts' lawsuit seeks to prevent the implementation of the law and preserve its ability to continue operating under its current business model. While the legal arguments will be addressed by the courts, the lawsuit itself raises an important question: Why are PBMs willing to spend significant resources challenging laws designed to separate PBM functions from pharmacy ownership? The answer may lie in the tremendous value that vertical integration provides to large PBM organizations." [Express Scripts, Inc. v. Blane, No. 26-9999 (M.D. Tenn. complaint filed Jun. 6, 2026)]  MORE >>

"The complaints ... mark the latest escalation in the legal battle over state efforts to regulate PBMs.... The litigation also underscores a growing conflict between states seeking to reshape the prescription drug marketplace and PBMs arguing that federal law preempts many of those reforms." [Pharmaceutical Care Mgmt. Ass'n (PCMA) v. Gillespie, No. 25-3200 (C.D. Ill. complaint filed Jun. 16, 2026); Pharmaceutical Care Mgmt. Ass'n (PCMA) v. Blane, No. 25-0816 (M.D. Tenn. complaint filed Jun. 15, 2026)]  MORE >>

"[T]wo-thirds of clients (66%) currently cover GLP-1s for obesity, and most intend to continue doing so. Few clients that do not cover GLP-1 drugs for obesity are considering adding them.... This finding is consistent with [WTW's] 2025 Best Practices in Healthcare Survey, where 57% of employer respondents indicated coverage of GLP-1 medications for obesity.... 74% are considering or already using a clinical wrap to support appropriate utilization, engagement and outcomes."  MORE >>

"Request disclosure of rebates for all formulary drugs.... Examine how rebates, guarantees and exclusions are defined in the contract. Small nuances in contract language can drive costs over time.... When a plan's PBM is incentivized to managing future price increases, prescription drug cost trend tends to improve.... Particularly for plan sponsors that signed their PBM contract years ago, it's worth exploring options, because drug pricing dynamics and PBM pricing models have recently changed dramatically."  MORE >>

"The PCMA is alleging that the PDAA will cause substantial harm to the association's members ... The PDAA was crafted to rein in the influential middlemen, which sit at the epicenter of the U.S. pharmaceutical supply chain and control the flow of drugs between pharmaceutical companies, insurers, pharmacies and patients.... [The Illinois law was enacted last July,] part of a larger wave of state legislatures across the country passing PBM reform legislation to the annoyance of market giants in the industry." [Pharmaceutical Care Mgmt. Ass'n v. Gillespie, No. 25-3200 (C.D. Ill. complaint filed Jun. 16, 2026)]  MORE >>

12 pages. "This request for information (RFI) solicits technical input on the services and business practices of pharmacy benefit managers (PBMs) and their affiliates to inform implementation of recent legislation. It specifically focuses on gathering information to inform two specific legislative requirements that are effective beginning calendar year 2028: restrictions on the remuneration that PBMs and their affiliates may receive for services in connection with the utilization of covered Part D drugs; and data reporting requirements....

"This request for technical input is narrowly focused on gathering information on current business practices to inform two specific requirements added to the Social Security Act by section 6224 of the Consolidated Appropriations Act, 2026 (CAA, 2026) ... [1] Definition of 'Pharmacy Benefit Manager' ... [2] Definition of 'Affiliate' ... [3] Definition of 'Bona Fide Service Fee' ... [4] Determination of 'Fair Market Value' ... [5] Pharmacy Payment."  MORE >>

"The DOL proposed rule (if finalized) and CAA 2026 encourage transparency and accountability between plan sponsors/fiduciaries and PBMs. With detailed initial and semiannual disclosures, drug-level pricing transparency, and enforceable audit rights, plan sponsors and fiduciaries can: [1] Compare PBM models and evaluate which approach delivers the best value. [2] Identify spread pricing exposure at the individual drug level. [3] Attempt to negotiate transparent pass-through compensation arrangements."  MORE >>

"On June 3, the [FDA] released a revised draft guidance on what drug and device manufacturers can say to health insurers, [PBMs], formulary committees, and similar organizations about their products.... The revision incorporates statutory changes US Congress made in 2023. Companies now have a single, clearer framework for sharing economic data about approved products and factual information about products still in development."  MORE >>

"Employer health plans have been using international drug sourcing for years. The strategy is straightforward.... For self-funded employers trying to deliver meaningful pharmacy benefits without surrendering to the pricing models of the domestic pharmaceutical market, it has been a practical and powerful tool. Recent litigation has complicated that picture."  MORE >>

"A plan sponsor's success in managing pharmacy spend depends less on which PBM model it selects and more on the rigor of its contracting, governance and oversight. Several levers consistently generate meaningful savings."  MORE >>

"Most patients who have taken a GLP-1 received their prescription through a primary care doctor or a specialist ... But as the uptake of telehealth has grown substantially ... millions of Americans [have] used online companies to meet a variety of their medical needs. Many of the companies have started offering GLP-1 medications for weight loss as demand for these drugs has exploded. But certain medication errors tied to GLP-1s have exploded too ... and physicians and telemedicine researchers worry that adverse experiences tied to telehealth companies are becoming more common."  MORE >>

"The PBM industry continues to evolve through legislative action, litigation, and voluntary industry changes. [This article provides] a brief round-up of recent developments including new federal and state legislation targeting vertical integration, an ERISA preemption challenge to California's PBM reform law, and a new pharmacy care model announced by Optum Rx."  MORE >>

"The new legislation aims to level the playing field. By restricting the power of PBMs....[The] Act would: [1] Give patients more choices in where they get their medication, ending the practice of steering customers to PBM-owned pharmacies. [2] Standardize drug payments so that pharmacies are reimbursed fairly, regardless of their size or ownership. [3] Increase transparency in drug pricing[.]"  MORE >>

"The U.S. House Committee on Education and the Workforce on May 21 advanced a series of bills prohibiting pharmacy benefit managers from providing kickbacks or referral fees to intermediaries [HR 7895], requiring hospitals to adopt accurate billing practices [HR 8684], and extending the deadline for plans to file Form 5500 disclosures [HR 7362]. The bills, each affecting plans governed by [ERISA], may now receive consideration from the full House of Representatives."  MORE >>

"The Education and Workforce Committee passed [bills on May 21 which would] ... increase health care transparency, lower prescription drug costs, and strengthen retirement security.... [1] Form 5500 Filing Simplification Act [HR 7362] ... cuts unnecessary paperwork for retirement and employee benefit plans by simplifying federal reporting requirements and updating filing rules. [2] PBM Kickback Prohibition Act [HR 7895] cracks down on PBM kickbacks and helps ensure health plan design decisions are made in the best interest of patients and employers -- not corporate middlemen. [3] Transparency in Billing Act of 2026 [HR 8684] ... increases transparency for workers and families by requiring hospitals to bill honestly about where services are being provided."  MORE >>

"​When adding coverage for weight and obesity care, consider how a long-term, adaptive model can deliver consistent clinical outcomes while maintaining financial predictability. For example, a framework that includes GLP-1 coverage for weight loss should be integrated with a broader, whole-person care model that combines medication with a proven behavioral and lifestyle program, clinical oversight and care coordination."  MORE >>

72% of plan sponsors say GLP-1s are already driving healthcare costs to a great or very great extent....Plan sponsors who continue to treat this as a utilization problem will see rising costs with limited returns. Those who treat it as a strategic financial decision will do something different: they will decide intentionally who gets access, at what cost, and for what outcomes. Because the question is no longer whether to cover GLP-1s, it’s whether you can afford to do it without a strategy."  MORE >>

"In final regulations ... [CMS] introduced several updates intended to simplify compliance and reduce administrative burdens ... This article outlines the key regulatory changes, including a new exemption for account-based medical plans from the Part D creditable coverage reporting requirements, and the phase-out and replacement of the former simplified determination method for determining group health plan creditable coverage status, and highlights practical considerations for plan sponsors preparing for the new requirements."  MORE >>

"Beginning today, TrumpRx.gov will feature more than 600 generic medications. Americans will be able to clearly and transparently understand the most competitive cash prices of their medications without insurance middlemen, encouraging them to compare against co-pays offered by their insurance company. Patients will be able to compare the best cash prices available to them at their local pharmacies and through delivery options offered by various private pharmacy programs."  MORE >>