News Archive

"[T]he interaction between the Proposed Rule and the CAA 2026 was a prevalent theme in the comments.... [C]ommenters made other legal arguments challenging the DOL's authority to proceed with the Proposed Rule ... Many comments addressed the feasibility of the effective date, the scope of the Proposed Rule, and the scope of the proposed audit rights."  MORE >>

"Pharmacy Benefit Manager (PBM) arrangements have long relied on rebates with limited transparency into true drug costs. Recent regulatory and market developments represent a shift toward greater transparency and better net pricing. These developments span a broad range of actors and approaches, including increased regulation of PBMs by the states, legislative, rule-making and agency actions by the federal government, and evolving market-driven responses. This post provides a high‑level overview of key developments and offers practical steps for health plan fiduciaries to consider[.]"  MORE >>

"Thirteen new drugs and one gene therapy have already received FDA approval in 2026, ... New oral GLP-1s are entering the market, changing usage patterns -- especially for weight loss treatment.... Patents are expiring for several key brand specialty and non-specialty drugs, clearing the way for new generic and biosimilar options in 2026.... Changes in the market are supporting list price reductions, a shift from rebates and to more aggressive price competition."  MORE >>

"These tariffs are aimed at pharmaceutical manufacturers, not employers.... Any impact on employer-sponsored health plans will depend on how manufacturers respond and how pharmacy benefit managers, or PBMs, translate those decisions into pricing, rebates, coverage decisions, and reporting. For many employers, this may not result in any meaningful near-term change. The main value right now is understanding whether your plan relies heavily on the kinds of drugs most likely to be affected."  MORE >>

"[B]eginning July 1, 2026, through December 31, 2027 ... [e]ligible individuals enrolled in Medicare Part D prescription drug plans will be able to access these medications at a predictable and affordable cost -- $50 for a monthly supply."  MORE >>

"The Tennessee General Assembly recently passed the Freedom, Access and Integrity in Registered Pharmacy Act, known as the FAIR Rx Act (SB 2040/HB 1959). The legislation targets vertical integration in the pharmacy market by prohibiting certain entities from owning or controlling a pharmacy while also owning or controlling a PBM and a health insurance issuer. This is not a minor transparency bill. It is not simply another reporting requirement. It is a structural reform bill."  MORE >>

13 pages. "To date, the Administration has reached voluntary MFN pricing agreements with 17 of the largest pharmaceutical manufacturers in the world. Moving forward, the Administration expects to reach similar agreements with most manufacturers of sole-source brand name drugs and biologics in the nation. In parallel, the Administration is working with Congress to codify those voluntary agreements into law to ensure that patients continue to benefit from price discounts. This report describes the MFN drug pricing framework and evaluates its fiscal effects."  MORE >>

"While most employers cover GLP-1s for diabetes, 67% of surveyed employers currently cover GLP-1s for weight management ... with many employers relying on various strategies to ensure the appropriate use of GLP-1s for weight management.... Of those covering GLP-1s for weight management, only 72% said they were likely to continue that coverage in 2027, while 10% said they likely would not, according to the survey. Companies that do not cover GLP-1s for weight management today are unlikely to add coverage in the future."  MORE >>

"Creditable prescription drug coverage is defined as coverage that is equal to or greater than the actuarial value of standard Medicare Part D coverage.... Plan sponsors can determine creditable status using either a simplified determination method or an actuarial evaluation. Employer Group Waiver Plans (EGWPs) and Retiree Drug Subsidy applicants are required to use actuarial valuation.... CMS introduced a new simplified determination -- optional in 2026 and mandatory in 2027 and beyond. The only change from 2026 to 2027 is a one percentage point increase in required value."  MORE >>

"Direct-to-consumer reimbursement models have emerged as a compelling alternative, enabling participants to obtain these medications at reduced prices while shifting claims processing outside traditional PBM frameworks. [This article outlines] the key legal and administrative considerations plan sponsors must address before adopting these arrangements."  MORE >>

"The US drug pricing environment is shifting rapidly ... States, federal agencies, and the courts are all driving reforms that affect pharmacy costs, benefit design, and contract strategy. Employers will face more variability, more oversight and more pressure to make informed decisions quickly.... This white paper summarizes the major forces shaping 2026 and provides practical, employer focused guidance on how to navigate this environment."  MORE >>

"Self-funded ERISA plans in Tennessee are not required to admit any-willing-provider to their networks or to refrain from financial incentives that direct participants to preferred pharmacies. Plan sponsors retain the flexibility to design pharmacy benefit programs, including tiered networks, cost-sharing differentials, and preferred pharmacy arrangements, without interference from the invalidated Tennessee provisions." [McKee Foods Corporation v. BFP Inc., No. 25-5416 (6th Cir. Apr. 7, 2026)]  MORE >>

"Direct‑to‑consumer platforms like TrumpRx.gov, Hims, Lilly Direct, and NovoCare now offer [GLP-1s] between $149 and $449 per month, cash pay. The obvious question: can we reimburse employees through an HRA for purchases made through these channels? In most cases, yes. But the compliance advice most employers receive says otherwise, and the reason is worth understanding."  MORE >>

"A bipartisan coalition of 45 state attorneys general ... has urged the U.S. [DOL] to ensure its proposed PBM transparency rule does not override state laws. The rule would require PBMs serving ERISA-covered plans to disclose pricing and rebate data to plan sponsors, but states want explicit protections for their own oversight powers. The move reflects growing scrutiny of PBMs[.]"  MORE >>

"The PBM regulatory landscape is evolving rapidly at both the federal and state levels, making it critical for [those] involved in the PBM space to stay apprised of developments in the industry as they happen.... This update ... highlights federal and state activity from October 2025 to mid-February 2026."  MORE >>

"Although the reporting and transparency requirements of the 2026 CAA are intended as 'PBM reform,' the applicable laws amended by the 2026 CAA directly govern plans and plan sponsors. [This article provides] a high-level overview of provisions in the 2026 CAA applicable to group health plans, including both ERISA plans and plans subject to the PHSA, such as publicly funded and governmental plans."  MORE >>

"Witnesses called out PBMs for failing to put patients first.... Chairman Tim Walberg (R-MI) asked about how consolidation within the PBM space is limiting choice. ... Rep. Burgess Owens (R-UT) discussed how PBMs have lost sight of their intended purpose.  ... In an exchange with Rep. Virginia Foxx (R-NC), Mr. Gelfand described the enormous power PBMs wield over the pricing, distribution, and accessibility of pharmaceuticals."  MORE >>

Video of April 22 hearing, with Opening Statement from Subcommittee Chairman Rep. Rick Allen (R-GA), and witness testimony from: [1] Mr. James Gelfand, The ERISA Industry Committee (ERIC); [2] Mrs. Chris Deacon, VerSan Consulting; [3] Professor Mariana Socal, Johns Hopkins Bloomberg School of Public Health; and [4] Ms. Hannah Anderson, America First Policy Institute.  MORE >>

"Employers, lawmakers, patient advocates, price transparency groups and more urged the [DOL] to quickly finalize a rule that would force pharmacy benefit managers ... to share more pricing and compensation information. PBMs did not feel the same, according to industry comments on the proposed regulation."  MORE >>

"Speaking [April 21] at Politico's Health Care Summit, the celebrity entrepreneur and cofounder of Cost Plus Drugs, a direct-purchase marketplace for generic drugs, painted the picture of an industry cowed by major insurers and pharmacy benefit managers."  MORE >>

"Rather than continuing to be squeezed by ever-higher—and often unsubstantiated—costs from traditional health insurance and pharmacy benefit management (PBM) firms, business are instead now putting their contracts up for bids from prospective partners that are willing and able to offer more affordable options."  MORE >>

"McKee confirms that there are limits to state PBM regulation. States may regulate PBM reimbursement rates and other costs, but when they: Require inclusion of all willing pharmacies in networks, or Prohibit differential copays and other steering mechanisms within networks, they are dictating ERISA plan structure and administration and risk preemption, at least as applied to self‑funded plans." [McKee Foods Corporation v. BFP Inc., No. 25-5416 (6th Cir. Apr. 7, 2026)]  MORE >>

"One nonprofit hospital system in Pennsylvania, Jefferson Health, said the cost of GLP-1 drugs has jumped to 40% of its insurance spending. As a result, the organization's CEO, Dr. Joseph Cacchione, stated the issue led to more than 600 employees being laid off. Last year, the costs left Jefferson Health's insurance arm with a reported loss of nearly $180 million."  MORE >>

"If finalized, the proposed regulations could significantly alter how employer health plans evaluate PBM arrangements.... Plan fiduciaries would have greater access to data necessary to assess whether PBM compensation is reasonable and whether PBM arrangements present conflicts of interest.... The new disclosure regime may affect contract negotiations, particularly regarding rebate pass-through structures, spread pricing arrangements, and audit rights and reporting obligations.... Greater transparency could increase litigation risk where PBM compensation appears excessive or inconsistent with fiduciary duties under ERISA."  MORE >>

"Sponsors of HRAs and other account-based plans, which are typically offered alongside major medical plans, will welcome the relief from providing burdensome and potentially confusing Part D creditable coverage notices. Sponsors of plans that remain subject to the disclosure requirements should use the 2027 parameters when determining whether their plans' prescription drug coverage is creditable for that year."  MORE >>