In a move that has rocked the pharma industry, Arkansas has passed the nation’s first‑of‑its‑kind law banning Pharmacy Benefit Managers (PBMs) from owning or operating their own pharmacies. The new law, which will officially take effect on January 1, 2026, seeks to prevent conflicts of interest, inflated drug prices, and anticompetitive behavior—including negative impacts on independent pharmacies that have driven some out of business.
This aggressive push for PBM reform echoes efforts being advocated at the federal level. In April, President Trump signed an executive order that includes measures to improve transparency into pharmacy benefit‑manager fee disclosures. The order requires the Secretary of Labor to issue regulations that will improve employer health‑plan fiduciary transparency into the direct and indirect compensation received by PBMs.
Industry Impacts
While the impetus for PBM reform on the federal level has been happening for some time now, the Arkansas law is sudden and sweeping. But what does it actually mean for the broader PBM space?
Operational Adjustments
It’s safe to say that large PBMs—including CVS Caremark, OptumRx, and Express Scripts—are watching the developments in Arkansas very closely. Affiliated with major health insurers, they control about 80 percent of the prescription‑drug market, and these new regulations will impact the way they do business in Arkansas significantly. This could include divesting from owned pharmacies and reevaluating their business models to comply with the new law. Such changes may lead to increased operational costs and potential disruptions in service delivery.
Financial Implications
The law could affect the financial dynamics of PBMs operating in Arkansas. Without the ability to own their own pharmacies, PBMs may lose a revenue stream, potentially impacting their profitability. Additionally, the requirement to reimburse pharmacies at or above the National Average Drug Acquisition Cost (NADAC) could increase expenses.
Legal and Regulatory Challenges
The PBM industry may pursue legal avenues to challenge the Arkansas law, arguing that it conflicts with federal regulations or disrupts established business practices. However, previous legal battles in Arkansas—such as the the Supreme Court’s unanimous decision upholding state regulations on PBM reimbursements—suggest there is a strong legal foundation for the law to stand on.
Industry Precedent
While the Pharmaceutical Care Management Association (PCMA) openly criticized the Arkansas law, citing concerns over reduced access and higher health‑care costs—other states, including Vermont, Texas, and New York, have recently introduced similar legislation. Will others follow suit? That remains to be seen.
Benefits to the Independents
Pharmacies in Arkansas will financially benefit from the new law, especially independent pharmacies in more rural areas that have been at risk of closing for years due to unfair PBM reimbursements.
The US‑Rx Care Difference
US‑Rx Care is a different kind of Pharmacy Benefit Manager. As an independent PBM, we deliver true fiduciary‑first pharmacy risk management to self‑insured employers with a singular focus on balancing cost and quality care. Everything we do is always in the best interest of our clients and their plan members—no financial conflicts of interest, no hidden profits, and total, unrestricted transparency.
Want to find out the difference a fiduciary‑first approach to PBM can make for you and your business? Let’s talk. Reach out now!
A growing number of employers are adding menopause-related benefits to their health and wellness programs, recognizing both the personal and business impact of this phase of women’s health.
According to a 2023 Mayo Clinic report, menopause-related symptoms are responsible for an estimated $1.8 billion in lost workdays annually in the U.S., largely due to absenteeism and diminished productivity.
As a result, employers such as Microsoft, IBM and several large financial institutions have already launched menopause initiatives. A 2024 Mercer report found that 15% of U.S. employers now offer menopause-specific benefits, compared to virtually none just a few years ago.
The rise of menopause benefits
Menopause is defined as the point when a woman has gone 12 months without a menstrual period, typically around age 52.
But the transition often begins much earlier. Perimenopause, the lead-up phase, can last several years and bring with it a wave of challenging symptoms: hot flashes, brain fog, insomnia, mood swings and more — that interfere with daily life and work performance.
Forward-thinking companies are starting to introduce menopause-specific benefits, including:
Flexible work arrangements.This includes remote options, reduced hours or flexible schedules to help manage symptoms.
Access to virtual care. These services provide access to menopause-trained providers, including reproductive endocrinologists.
Mental health support.This can be offered through your employee assistance program and mental health platforms.
Hormone replacement therapy coverage. Financial benefits like flexible spending accounts and health savings accounts allow employees to use tax-advantaged funds for services such as HRT, which is typically not covered by group health plans. Self-insured employers can choose to include coverage in their plans.
Environmental accommodations. This can include providing portable fans, relaxed dress codes, wellness rooms and more.
Educational resources. Provide access to digital content on menopause health and treatment options, including webinars, videos, podcasts, journals and articles.
Support groups. These can be online or in person and help combat isolation and stigma.
The business case
Women between ages 45 and 64 represent about 17.5% of the U.S. workforce, according to the Department of Labor. Yet a Biote survey found 17% of women ages 50 to 64 have quit or considered quitting due to menopause symptoms.
Supporting this group brings several business benefits:
Retention of top talent: Many women face menopause symptoms just as they reach peak leadership potential.
Improved productivity: Mitigating symptoms can reduce time off and help employees stay focused.
Legal risk reduction: Inclusive policies may help companies comply with workplace protections under laws like the Pregnant Workers Fairness Act.
Enhanced employer brand: Women with access to menopause benefits are more likely to recommend their employer, according to a joint 2023 study by Bank of America and the National Menopause Foundation.
Communication is key
Even the best benefits can fall flat if employees don’t know they exist. Best practices include:
Hosting informational sessions about menopause support programs.
Training managers on how to speak sensitively about menopause in the workplace.
Highlighting these benefits in open enrollment materials and onboarding packets.
Ensuring that digital portals and HR systems clearly identify menopause-related resources.
The takeaway
As menopause-related benefits gain traction, employers should assess whether their current health and wellness offerings meet the evolving needs of midlife employees. Proactively addressing this gap can support compliance, improve retention and strengthen workforce stability.
In a major announcement, America’s Health Insurance Plans (AHIP) said that more than 50 major insurers — including UnitedHealthcare, Aetna, Cigna and various regional Blue Cross Blue Shield plans — have pledged to significantly streamline the prior authorization process and improve the patient care experience.
This shift could bring relief to more than 250 million Americans enrolled in commercial, Medicare Advantage and Medicaid managed care plans.
What’s changing?
The insurers committed to a six-part plan to reduce the administrative burden of prior authorization, modernize approval processes and improve the speed of care. Key changes include:
Standardized electronic prior authorization submissions, targeted for 2027.
Reduced prior authorization requirements for certain services, effective in 2026.
Continuity of care protections for patients switching plans mid-treatment, ensuring prior approvals are honored for 90 days.
Clearer communication about authorization decisions and appeals, set for implementation in 2026.
Real-time approvals for at least 80% of electronic requests by 2027.
Mandatory medical review of any denial based on clinical grounds, which is already in effect.
Evolution of prior authorization
Prior authorization was originally intended as a cost-control measure to ensure treatments are medically necessary and cost-effective. But for many patients and businesses, it has become a bureaucratic nightmare.
According to the American Medical Association’s (AMA) 2024 survey of practicing physicians:
93% reported that prior authorization delays access to necessary care.
82% said it sometimes causes patients to abandon treatment altogether.
88% believe it increases overall health care costs through ER visits, extra office appointments and hospitalizations.
Nearly one in three reported that the process led to a serious adverse event, including hospitalization or even permanent harm.
While these delays have real consequences for health plan enrollees, for businesses that provide group health insurance, they can translate into reduced employee productivity, higher out-of-pocket costs for workers and lower satisfaction with benefit plans.
In recent years, there’s been a growing backlash against prior authorization and the toll it takes on time-sensitive care. Until now, insurers have been slow to change. But as dissatisfaction has grown, insurers like UnitedHealthcare and Aetna have started to make moves — such as eliminating requirements for certain medications or bundling approvals for cancer-related imaging tests.
AHIP’s new industrywide pledge is the most sweeping effort yet and signals that insurers recognize the pressure to act.
Will it work?
While the commitment marks a major policy shift, questions remain about how fast and how fully these changes will be implemented. As the AMA notes, similar voluntary pledges in the past haven’t produced substantial results. In fact, only 10% of physicians surveyed said they currently work with insurers offering programs that exempt “trusted” providers from repeated approvals.
Still, the promise to move toward real-time decisions and reduced authorization burdens — especially for high-performing doctors and common procedures — could ease friction and improve patient experience.
The takeaway for employers and health plan buyers
If AHIP’s reforms are implemented as promised, the impact on enrollees could be significant:
Faster care: Less waiting for approvals could reduce time off work and lower stress.
Lower costs: Fewer delays can prevent complications that lead to higher downstream medical bills.
Simplified processes: Standardization and real-time digital systems will cut down on paperwork and confusion.
Health insurance is back on the legislative agenda in Washington, with several proposals that could reshape how employers provide coverage to their workers.
Three bills gaining traction in the House aim to overhaul parts of the Affordable Care Act (ACA), expand access to group health plans for small employers and protect the use of stop-loss insurance for self-insured plans.
Here’s a summary of what’s on the table and how it could affect employers.
Health Care Fairness for All Act
Key change: Repeals the ACA employer mandate
Introduced by Rep. Pete Sessions (R-Texas), this bill would eliminate the ACA’s employer health coverage mandate, the requirement that companies with 50 or more full-time employees offer affordable coverage or face penalties.
While the bill removes this mandate, it maintains several popular ACA provisions, including protections for preexisting conditions and guaranteed issue requirements.
To prevent people from enrolling in coverage only after becoming ill, the bill would impose a 20% late-enrollment penalty on individuals who join a plan without maintaining prior coverage for at least 12 months.
Another significant provision is the introduction of “Roth HSAs,” which would replace traditional health savings accounts. Unlike HSAs now, contributions would be made with after-tax dollars, but unlike current HSAs, they could be paired with low-deductible plans and not only high-deductible health plans.
Association Health Plans Act
Key change: Allows small businesses to band together for group health insurance
Backed by Rep. Tim Walberg (R-Mich.) in the House and Sens. Roger Wicker (R-Miss.) and Rand Paul (R-Ky.) in the Senate, the AHPA would revive and expand rules allowing small employers and self-employed individuals to purchase health insurance as a single group.
By pooling together, these employers could access large-group health plans that often offer better rates and more plan options than small-group or individual plans. Supporters argue this would increase access to affordable coverage for millions of workers who currently lack employer-sponsored insurance.
Self-Insurance Protection Act
Key change: Shields stop-loss insurance from state and federal regulation
This bill, introduced by Rep. Robert Onder (R-Mo.), aims to preserve small employers’ ability to self-insure their group health plans by protecting stop-loss insurance arrangements from being classified or regulated as traditional health insurance. Some states have attempted such reclassification to restrict their use among small employers.
Stop-loss insurance reimburses self-insured employers for catastrophic claims beyond a certain threshold. These arrangements make self-funding viable even for smaller businesses with less predictable health care costs.
Proponents say the bill levels the playing field for small employers that want to use self-insurance to control costs. Detractors argue that such plans, when not subject to the same rules as fully insured policies, may not offer sufficient consumer protections or minimum benefits.
The takeaway for employers
Currently, all three bills are awaiting a hearing in the House Education and Workforce Committee, and as of this writing, there have been no votes on the measures.
If these bills gain momentum, employers — especially smaller ones — could see more flexibility and options when it comes to providing health benefits.
While these bills still face political hurdles, they signal where health policy may be headed and what strategies employers may want to prepare for in the years ahead.
Watching their group plan premiums climb higher with each passing year, some employers start looking into alternative funding strategies in hopes they can get a better handle on their employees’ health costs.
While group plans are the standard, larger employers have typically had more options for funding their group health coverage. But now even small and medium-sized employers – even companies with fewer than 100 employees – can benefit from alternative funding approaches.
There are three main types of alternative funding strategies that are available to employers:
Captives
Private exchanges
Full and partial self-funding.
Captives
With a captive, multiple employers pool their resources and share the risk in providing health insurance to their employees. It is essentially a self-insured pool built into a captive insurance company (an insurer that is owned by the entity that created it). The captive has staff that will administer the health plan.
Captives are also multi-year agreements, so once an employer commits to make it worth their investment, they need to stick with it for a period of time.
Group captives will often have a specific funding mechanism that is broken down into four layers:
Layer 1: The employer is responsible for the first $25,000 of any claim made by one of its employees.
Layer 2: All employers involved in the captive will share the costs of that claim if it exceeds $25,000, up to $250,000.
Layer 3: For claims that cost more than $250,000, the captive will secure reinsurance coverage to cover amounts above that level. This reinsurance is also called “stop-loss” insurance.
Layer 4: Another layer of protection known as “aggregate stop-loss” coverage protects each employer in the captive for the total claims of their employees, ranging from 115% to 125% of expected claim costs in a year.
Private exchanges
Typically, businesses using a private exchange will offer employees a credit that can be applied toward the purchase of a health plan. Employees can then access a variety of health plans through an online portal and can chose and enroll in plans that meet their needs.
Private exchanges are run by insurance carriers or consultancies, and plans on the exchange are regulated as group coverage. Employees shopping on these exchanges are not eligible for the Affordable Care Act’s tax credits or cost-sharing subsidies.
Most employers currently using private exchanges are large; therefore, most private exchange plans are regulated as large-group coverage and are not part of the ACA’s single risk pool. However, to the extent that smaller employers participate in private exchanges, they are subject to the ACA’s small-group rating regulations and risk-pool requirements.
One of the main features of private exchanges is that they enable employees to comparison-shop among multiple health insurance plans.
Self-insuring
There are many different types of self-insurance, from minimum-premium or risk-sharing arrangements to a fully self-funded plan, in which the employer is responsible for all claims.
Employers can choose from:
Retrospective premium arrangements – The insurer will credit back a portion of the unused premium to the employer (typically as a credit for the following year). This is often used in a fully insured arrangement.
Minimum premium arrangements – The employer pays fixed costs (administration charges, stop-loss insurance and network access fees) and claim costs up to a maximum liability each month.
Partial self-funding -The employer takes on more liability and pays fixed costs (administration, network access, stop-loss premiums and some fees and taxes). It’s partial self-funding because the employer will purchase individual stop-loss insurance, which caps the employer’s liability on any given claim to a certain amount, say $50,000.
That way, the employer is self-insuring most of their employees’ medical needs, but is protected in case some of those claims become catastrophic.
Full self-funding – This is like partial self-funding except that there is no stop-loss insurance and the employer is responsible for all costs that are not shared by its employees. This kind of arrangement is usually only available to large employers.
The takeaway
These alternative funding approaches are what is available now. But the industry is innovating to making health care and insurance more affordable for all involved.
Gaining access to plan claims data and expenditures can help employers identify their plan’s main cost drivers and any under- or overutilization. Employers whose plans are spending less than average can use that information as leverage if they want to negotiate for better rates or plan structure.
But how much data an employer can get — and what they can do with it — often depends on how their plan is funded. Employers who purchase group health insurance have the least amount of access to data, but if they work with their broker, they can sometimes gather important insight into what spending is driving their plan’s costs. Self-insured employers have the most access since they are the insurer and contract with administrators that handle their claims.
Fully insured vs. self-insured plans
Employers in fully insured plans can take steps to improve access to information, including:
Requesting quarterly reports from their insurer or broker showing trends in claims by category (e.g., ER visits, specialty drugs).
Asking for benchmarking data that compares their plan’s usage and cost patterns to similar companies.
Negotiating for more transparency during renewal discussions. Some carriers offer access to online dashboards or population health tools that provide at least a general overview.
Self-insured employers and those using level-funding (a hybrid arrangement between fully insured and self-insured) have more access to granular data, which they own. They typically contract with a third-party administrator to handle the plan’s expenditure and collect important data that can shed light on cost drivers.
What you can do with data
With access to the right claims information, employers can:
Identify high-cost claimants (scrubbed of identifying information) and track chronic conditions like diabetes, hypertension and musculoskeletal issues.
Break down spending by demographics to tailor benefits to age, gender and family status.
Monitor utilization patterns, such as unnecessary emergency room visits or low preventive care adherence.
Use predictive modeling to forecast future claims and adjust the plan design accordingly.
Why this data matters
Access to claims and utilization data allows employers to align their plan benefits with employee needs while controlling unnecessary costs. Here’s how employers can benefit:
Initiating targeted communication: If employees overuse the ER or underuse preventive services, employers can launch education campaigns to steer behavior.
Plan optimization: Data can show whether adding a mental health benefit or removing a redundant offering would deliver better value.
Vendor performance: Employers can evaluate if programs like telehealth, disease management or wellness initiatives are delivering a return on investment.
Smarter renewals: Employers can use their data to negotiate more effectively with vendors or consider alternative funding arrangements.
Options for smaller employers
If you’re a smaller firm and don’t have access to deep analytics, you still have options:
Ask us to request insurer data and perform analysis on your behalf and adjust your plan design if necessary.
Use carrier-provided tools, if available, such as reporting dashboards, health risk assessments or plan modeling software.
Review claims data at least quarterly to identify cost trends, any under- or overutilization or cost anomalies.
