When it comes to pharmacy benefit management, not all PBMs are created equal. Many traditional PBMs rely on opaque pricing models, hidden rebates, and misaligned incentives that can drive costs up instead of bringing them down. For benefits consultants, asking the right questions up front is key to ensuring transparency and delivering measurable savings.
Below is a checklist of essential questions every benefits consultant should ask a prospective PBM, along with red flags and differentiators to look for.
How is your pricing structured?
Why it matters: Traditional PBMs often profit from spread pricing and rebate arrangements that aren’t in the client’s best interest.
Red flag: If the PBM avoids explaining how they make money, chances are the incentives are misaligned.
What to look for: A pass-through pricing model with full transparency. At US-Rx Care, we don’t profit from rebates; we align savings directly with the plan sponsor.
Can you guarantee clinical savings, not just discounts?
Why it matters: Discounts sound good, but they don’t always translate into lower net costs. Without effective clinical management, “discounted” drugs are only solving for one piece of the puzzle.
Red flag: A PBM that only talks about discounts without showing outcomes data.
What to look for: Evidence-based clinical oversight that ensures patients are on the right drug at the right time, preventing unnecessary spend.
How do you handle specialty medications?
Why it matters: Specialty drugs represent less than 2% of prescriptions but more than 50% of drug spend. This is where PBMs often inflate margins.
Red flag: Limited transparency around specialty sourcing and pricing.
What to look for: Programs that ensure clinical appropriateness and offer alternative sourcing strategies. US-Rx Care consistently delivers significant savings on specialty medications without reducing access or quality.
What level of transparency do you provide?
Why it matters: A PBM should be a partner, not a unknown variable. Without visibility, consultants and plan sponsors can’t validate true performance.
Red flag: Reporting that’s overly complicated or excludes certain fees, rebates, or data.
What to look for: Full transparency in contracts, reporting, and outcomes. US-Rx Care provides clear, auditable reports so consultants can demonstrate value with confidence.
How do you align with fiduciary responsibility?
Why it matters: Plan sponsors have a fiduciary duty to act in the best interest of their members. A PBM that prioritizes its own profits puts employers at risk.
Red flag: Any PBM that claims savings but can’t demonstrate alignment with ERISA requirements.
What to look for: Fiduciary-focused solutions that ensure plan sponsors meet their obligations. US-Rx Care contracts are built to protect both the plan and its members.
Key Takeaway for Consultants
A PBM should work for the client, keeping their best interests, and those of the members, at the forefront. By asking these critical questions, benefits consultants can uncover red flags and position themselves as trusted advisors who deliver real value.
We’ve built our model around transparency, fiduciary alignment, and clinically driven savings. The result? Lower costs, better outcomes, and confidence that your PBM is truly on your side.
Discover how US-Rx Care can deliver measurable savings and transparency for you. Connect with us today at usrxcare.com/contact.
If you view annual open enrollment as a simple box-checking exercise, you’re likely missing out on helping your staff get the most out of the benefits you provide.
Instead, if you approach open enrollment as a chance to strengthen employee engagement, control costs and help your workforce understand the full value of your benefits program, you’ll likely boost participation and satisfaction among your staff.
With health care costs rising, financial stress growing and multiple generations in the workforce, employers need to approach open enrollment as a strategic initiative rather than a compliance deadline. This is more important than ever given rapidly rising premiums that will affect both your organization and your staff.
Here are seven best practices to keep in mind:
1. Focus on generational needs
Employees at different life stages want different things from their benefits:
Gen Z often looks for flexibility and mental health resources.
Millennials focus on balancing family and financial security.
Gen X may prioritize saving for retirement.
Baby boomers often care most about health coverage and stability.
Tailoring communication and plan design to these priorities can boost engagement across the board.
2. Avoid two big mistakes
Employers often make two main mistakes you’ll want to avoid:
Overloading employees with materials and presentations full of jargon. This is a sure way to lose their interest.
Failing to provide the necessary support to help them make decisions about which plan to choose.
Keep messaging simple, practical and easy to understand. Provide comparison tools, FAQs and one-on-one support when possible so employees don’t feel lost.
3. Do what works
Personalize your benefits education by providing tailored communications for each generation in your workplace. Use multiple communication channels like text messages, e-mail, print materials and the company intranet.
Help employees understand how benefits support their physical and mental health as well as their long-term financial security.
4. Provide year-round benefits communications
Regular benefits communications throughout the year can make open enrollment much easier for your staff. Some ideas include:
Reminders about their benefits and how they can use them.
Micro-learning tools, which deliver training in short, focused lessons through platforms like mobile devices and learning management systems. These tools improve knowledge retention and boost engagement.
Fact sheets on the benefits they are eligible for to help them discover options they may not know about but would like to have.
5. Plan ahead
The most effective open enrollment strategies are carefully planned. As part of this process:
Review last year’s open enrollment results.
Set clear goals.
Segment your employee population to identify gaps and opportunities.
Track outcomes so you can improve each year.
6. Consider new tech
Digital decision-support tools, including AI-driven platforms, can simplify open enrollment by providing employees with personalized plan recommendations.
These tools also give HR teams valuable data on employee behavior and preferences, which can guide future plan design and communication.
7. Play up the benefits of benefits
Frame your offerings as a stabilizing force. Emphasize that benefits provide consistency and protection when life is unpredictable, giving employees confidence that their health, income and families are supported no matter the circumstances.
By framing benefits as a safety net, you can show your staff how these programs help provide stability in daily life.
Takeaway
Employers who approach open enrollment strategically — with a focus on affordability, engagement and education — can turn a required process into a competitive advantage.
By meeting employees where they are and communicating clearly, you reinforce the value of your benefits program and strengthen trust within your organization.
The Departments of Labor, Treasury and Health and Human Services announced that they will no longer enforce a 2024 rule limiting short-term health insurance to three months.
The decision leaves the door open for insurers to once again issue these policies for up to three years, as they were permitted under rules implemented during President Trump’s first term. The agencies emphasized that the rule itself remains in place but said they “do not intend to prioritize enforcement actions” against plans that exceed the Biden-era restrictions.
Officials also signaled that they are considering further changes to how these policies are regulated, though no timeline was outlined.
A shifting regulatory landscape
Short-term health plans have been a political football across three administrations.
In 2016, the Obama administration finalized a rule limiting the plans to three months, calling them temporary stopgaps.
In 2018, Trump extended the maximum duration to one year and allowed renewals up to three years. Sales surged after that change.
In 2024, the Biden administration rolled back the expansion, capping the plans at three months with no more than four months of total coverage including renewals.
With the latest move, enforcement of that cap is on hold, giving insurers room to once again sell longer-duration plans.
How the plans work
Short-term policies are typically less expensive than Affordable Care Act-compliant coverage because they are not subject to ACA rules. These plans were originally envisioned as a bridge between jobs or coverage transitions, not as long-term solutions.
For smaller employers that are not subject to the ACA’s mandate to offer affordable health coverage, short-term policies could be an option for workers seeking lower-cost alternatives.
But because short-term coverage is distinct from comprehensive health insurance, employers evaluating whether to steer workers toward these plans should understand the trade-offs:
Preexisting conditions can be excluded.
Coverage can be denied based on health history.
Annual and lifetime benefit caps may apply.
Preventive care, maternity care and mental health services are often not included.
No protection under ACA consumer safeguards such as the No Surprises Act or parity requirements for mental health.
Short-term plans can also exclude certain benefits that ACA plans are required to cover.
State restrictions
While federal regulators are stepping back, states still control whether these plans can be sold within their borders.
Fourteen states plus the District of Columbia bar them altogether, including California, New York and New Jersey. Other states allow them but impose strict duration limits or conditions that make them impractical for insurers to offer.
Potential changes ahead
The agencies noted they are considering additional adjustments to the rules governing short-term plans. Possible areas of change could include:
Redefining the maximum duration,
Revisiting required consumer disclosures,
Imposing new standards for renewals, and
Allowing for stacking of policies.
Any proposed rulemaking would undergo a public comment process before becoming final.
Takeaway for employers
The federal decision creates uncertainty in the market, with enforcement discretion now favoring longer short-term policies but no clear timeline on new rules.
Employers with fewer than 50 employees may see these plans as a possible option for workers, but larger employers remain bound by ACA requirements to provide affordable, minimum-value coverage.
As the agencies move toward potential new regulations, employers should monitor developments closely and weigh the risks and limitations of short-term health plans before considering them as part of a benefits strategy.
Employers are preparing for what could be the steepest annual increase in health care costs in more than a decade, and many are considering plan design changes, including cost-shifting, to buffer the impact, according to a new report.
The “2026 Employer Health Care Strategy Survey,” conducted by the Business Group on Health, found that business executives project a median 9% rise in costs for 2026, but expect a 7.6% increase after making plan design changes to address major cost drivers. Here are the biggest concerns and how surveyed employers plan to address them.
1. Obesity treatments add pharmacy pressure
Pharmacy spending has grown to nearly a quarter of employer health care costs, driven largely by demand for GLP-1 drugs such as Wegovy, Mounjaro and Zepbound. Employers report that 79% have already seen increased use of these medications, and another 15% expect growth in the years ahead as the drugs gain FDA approval for additional conditions.
These treatments, effective for both diabetes and weight loss, often cost more than $1,000 per month. Employers are responding by:
Requiring “step therapy,” which involves trying proven, less expensive methods or medications before prescribing a GLP-1,
Limiting prescriptions to employees with diabetes and a qualifying body mass index,
Requiring prior authorization,
Mandating participation in weight management programs,
Approving prescriptions only from designated providers, and
Reducing GLP-1 coverage altogether.
2. Cancer drives long-term costs
For the fourth straight year, cancer has topped the list of conditions driving employer health care expenses. Rising diagnoses, delayed preventive care during the pandemic and an aging workforce are combining to push treatment costs higher.
In response, more employers are expanding cancer prevention and screening benefits, removing age limits for preventive screenings and covering access to cancer centers of excellence. About half of large employers expect to offer such centers by 2026, with more considering them by 2028.
3. Mental health demand continues to grow
Nearly three-quarters of employers report higher use of mental health and substance use disorder services, with another 17% expecting further increases soon.
While nearly all employers now offer mental health support, the challenge is balancing costs with access to appropriate care. Larger employers with more resources are providing access to centers dedicated to acute mental health conditions.
Cost-shifting and vendor changes
More employers are considering passing some of the health care cost burden onto employees. According to a recent Mercer survey, half of large employers said they will likely:
Increase employee premium cost sharing,
Raise deductibles, and/or
Hike out-of-pocket maximums in 2026.
In the Business Group on Health study, most employers said they would at least consider shifting costs to workers if needed.
At the same time, companies are rethinking vendor relationships. Forty-one percent reported changing or reviewing pharmacy benefit managers, while others are reassessing wellness and medical benefit partners.
Transparent PBM models and alternative health plans are gaining traction as employers look for greater value and predictability.
Recommendations
The Business Group on Health report noted that employers can do more than pass along costs to workers, by:
Assessing the effectiveness of benefit programs and vendors, and eliminating those that deliver limited value.
Helping employees — through training and an open-door policy for questions — use plan resources and navigation tools to find providers that deliver high-value care.
Encouraging staff to stay on top of check-ups, doctor visits, medications, screenings, tests and immunizations.
Requiring vendor partners to adopt transparent and sustainable financial models, particularly for pharmacy benefits.
As the year-end open enrollment period approaches, now is the time to fine-tune your benefits, and that starts with surveying your employees about their views of your current offerings.
There should be more to this effort than checking boxes. It’s important that you elicit an honest assessment from your employees, and once you have their responses you need to process and analyze them with the goal of exploring changes that will benefit your staff.
Surveys are not exercises in futility. A recent study by Aflac found that while four out of five employers think their workers are satisfied with their benefits, only three in five employees say the same. That disconnect can result in employers offering benefits year after year that their staff may not value.
Offering the wrong benefits can be costly, considering that benefits account for between 30% and 40% of total compensation, according to the Bureau of Labor Statistics. That’s a lot to spend on something you don’t know is generating a solid return on investment.
Areas you may want to cover in your survey include:
General satisfaction with benefits and whether there are any they want but you don’t offer.
Health care coverage affordability, coverage depth and network satisfaction.
Participation in wellness programs, satisfaction with mental health support and learning opportunities.
Overall impressions, understanding and usefulness of current benefits.
You may want to dig deeper into views on your most important benefit, group health insurance, by asking questions like:
How well does the current plan cover your needs?
Do you feel the current plan’s deductibles and copayments are fair?
Do you believe the current plan offers good value for the cost?
How easy is it for you to find in-network providers for the health care you need?
Are there any specific types of specialists or facilities you wish were more accessible in our network?
How easy is it to understand your benefits and how to use them?
How can we better communicate information about the health plan?
How satisfied are you with the customer support related to the health plan?
Digging deep
The next step is picking through the answers to identify trends and opportunities. As your health insurance broker, we can help digest the information and develop a plan for you. We can also segment the findings by age, family status (kids or no kids) or job function to better personalize offerings that match your employees’ needs.
Once we do that, you can prioritize which potential actions make the most sense, are feasible and would make the largest impact. We can then make a plan that includes:
Mid-term changes: Plan design or contribution changes
Long-term initiatives: Introducing a new benefit category
Final thoughts
Even small improvements show employees that their voice matters.
Just remember that many people have short attention spans, so ensure the surveys don’t take longer than five or 10 minutes to complete.
Also, arrange for the surveys to be submitted anonymously so your staff will feel free to speak their minds.
Whatever changes you decide to make must also be communicated to the employees, so they understand what’s coming and why the changes are being made. This shows that you took the survey seriously and responded with action.
Your transparency will build credibility, especially if changes take time.
“Operating with a true risk management focus and always in the best interests of the client is very liberating for health plans and employers in terms of the strategies we can provide to benefit plan sponsors and participants…we believe that the fiduciary mindset offers a valuable roadmap for what every organization should expect from all vendors, including their PBM and health plan carriers.”
-Renzo Luzzatti, President, US-Rx Care
It’s true—when facing the realities of just how expensive pharmacy benefits have become, more and more groups are realizing that the traditional PBM model just isn’t working in their favor. For those looking for both savings, integrity, and compliance, the fiduciary model has proven to be nothing short of game changer.
An ‘F’ Word that Packs a Punch
In the health benefits space, the term “fiduciary” carries some serious weight. Under the Employee Retirement Income Security Act of 1974 (ERISA), a fiduciary is defined as “any person or entity that exercises, administers, or advises discretionary control over plan management and assets.” And this comes with a crucial legal obligation: to act solely in the best interests of the plan and its participants.
In simpler terms, a fiduciary PBM must:
Prioritize the plan and its members above all else
Avoid all conflicts of interest, including third-party incentives
Disclose all financial arrangements
Provide total transparency on costs and utilization
Unlike traditional PBMs that often profit from opaque deals, rebates, and spread pricing, a fiduciary PBM removes these hidden profit centers entirely. This level of transparency enables better decision-making and ensures that cost-saving strategies aren’t just smoke and mirrors—they’re real, measurable, and aligned with your best interests.
Results That Speak for Themselves
Groups who move to a fiduciary PBM model—like US-Rx Care—often experience immediate and significant cost reductions by:
Eliminating wasteful spending
Optimizing drug utilization
Getting back 100% of negotiated savings to plan sponsors
But the true fiduciary advantage is more than just savings. It’s about aligning your company’s values and fiduciary duty with its PBM. It’s about accountability. And ultimately, it’s about doing what’s right for your employees—providing them with access to high-quality, affordable care without compromise.
The result? A sustainable solution that delivers better care for employees and a healthier bottom line for your business.
The US-Rx Care Difference
Have you been told: “You should be happy with annual increases that don’t reach double digits.” This is a myth that has pervaded the industry for years by both PBMs and those hanging onto the status quo. At US-Rx Care, we have never accepted the status quo. We provide self-insured employer and health plan employees with fiduciary compliant, pharmacy benefits risk management services that leverage a level of clinical rigor, administrative tools, perspectives, and approaches that have been honed, perfected, and time-tested for close to three decades. Our clients typically see between a 30-50% reduction in pharmacy benefits spend—with no change in benefit designs and minimal member disruption. Plan participants also typically enjoy a 30% reduction in out-of-pocket costs and are appreciative of the time and effort expended on their behalf to optimize their drug therapy and lower their spend.
What can the fiduciary PBM model deliver for you and your business? Let’s talk! Schedule a meeting at usrxcare.com/contact.
