PBM reform is moving from policy discussion into legislation, proposed regulation, and enforcement activity.
Recent government action has brought greater attention to how PBMs make money and whether plan sponsors have enough information to oversee those relationships. Employers and health plans are facing increasing pressure to understand the agreements underlying their pharmacy benefits, even as the regulatory landscape continues to evolve.
The momentum is meaningful, but it does not make existing PBM contracts safer by default.
New requirements may improve disclosure or place limits on certain practices. They cannot rewrite an agreement that restricts audit access, preserves conflicted revenue, or keeps important financial information beyond the plan’s reach.
That work still begins with the contract.
Reform Is Changing Expectations Before Every Detail Is Settled
The regulatory picture continued to develop throughout the second quarter of 2026. The Consolidated Appropriations Act included new PBM-related provisions, and the Department of Labor proposed a fee-disclosure rule focused on PBM compensation.
Under the proposed rule, PBMs would have to provide plan fiduciaries with more information about payments received by the PBM and its affiliated businesses. This could include compensation tied to rebates, pharmacy arrangements, administrative services, and other revenue connected to the plan’s pharmacy benefit. The proposal is intended to help fiduciaries determine whether the arrangement and its fees are reasonable under ERISA.
The Federal Trade Commission has also continued to challenge PBM practices through enforcement activity and settlements, keeping attention on business practices that may affect drug costs, pharmacy access, and competition. Together, these federal actions reflect growing interest in the financial relationships behind pharmacy benefits, not only the prices or guarantees presented to plan sponsors.
US-Rx Care tracks these policy developments in The Fiduciary Files, a quarterly newsletter created to help employers, health plans, and advisors understand how changes in PBM oversight may affect their responsibilities and pharmacy benefit strategies. The Q2 edition provides a closer look at these developments and the considerations they raise for plan fiduciaries.
Taken together, these actions are raising the bar for what plan sponsors are expected to understand about their pharmacy benefit arrangements. It is no longer enough to focus on headline figures like pharmacy discounts or rebate guarantees. Fiduciaries are increasingly expected to understand how the full arrangement operates and whether the PBM’s financial interests align with the plan.
At the same time, the framework is still taking shape. Key elements remain unsettled, and the practical impact of new rules will take time to fully emerge.
For now, employers and health plans are left with a moving target:
- Proposed rules may change before finalization
- Implementation timelines may extend over several years
- Legal challenges could reshape or delay certain requirements
Waiting for full clarity may feel prudent. In practice, it can also mean operating under contracts that were never designed in your best interest.
Make Sure Audit Rights Work in Practice
The presence of an audit provision does not necessarily mean the plan has meaningful audit access.
Some agreements narrow the records available for review. Others restrict the auditor, limit how often an audit can occur, or exclude information held by affiliated businesses. These conditions can make it difficult to verify whether pricing and payments followed the agreement.
A workable audit provision should allow the plan to tie claims to the relevant contract terms. It should also provide access to the records needed to verify the PBM’s performance.
When reviewing audit language, plan sponsors should look closely at:
- Which records and revenue sources may be examined
- Whether affiliated entities are included
- Who may conduct the audit
- What remedies are available when discrepancies are found
Auditability should provide a practical method of verification, not simply a right that exists on paper.
Contract Restrictions Can Limit the Plan’s Options
PBM agreements often shape more than pricing. They can also determine which pharmacies, clinical programs, and outside solutions the plan may use.
Required use of a PBM-owned mail or specialty pharmacy may create another source of revenue for the PBM directing the prescription. Restrictions on independent programs can also prevent the plan from pursuing a lower-cost or more appropriate option.
These provisions deserve attention because they affect the plan’s ability to act after the contract is signed. A plan sponsor may identify a better approach but discover that the agreement prevents its implementation. In that situation, more information does not produce more control.
The contract should preserve enough authority for the plan to evaluate alternatives and make decisions based on the interests of the plan and its members.
Fiduciary Governance Creates a More Durable Standard
A PBM contract may remain in place through several rounds of legislative debate and regulatory change. The plan’s responsibility to oversee that agreement continues throughout the full term.
Fiduciary governance provides a consistent standard for doing so. Rather than measuring the relationship only against the latest disclosure requirement, it considers whether the arrangement serves the best interest of the plan and its members.
That standard should guide the selection process and continue after implementation. It should influence contract negotiations, ongoing review, and the way pharmacy benefit decisions are made and documented.
US-Rx Care operates as a fiduciary pharmacy benefit manager under a legally binding obligation to act in the best interest of the plan and its members, fully conflict free. Its compensation does not depend on spread pricing or retained manufacturer revenue, and it does not own pharmacies that could benefit from dispensing decisions.
The result is a model built to support the plan’s interests rather than profit from higher pharmacy costs.
Build the Contract for the Environment Ahead
PBM reform is moving, but no employer or health plan can predict exactly where it will lead. Buyers can still make informed decisions about the agreements they enter today.
A stronger contract should include the following elements:
- A full and transparent view of PBM compensation, with the ability to verify how and where revenue is generated
- Clear audit and reporting rights that allow the plan to validate pricing, rebates, and affiliated entity payments
- No terms that protect affiliated revenue streams at the expense of the plan’s financial outcomes
- Sufficient flexibility for the plan to act when a better clinical or cost-effective option becomes available
- Alignment with the fiduciary responsibilities the plan sponsor is required to uphold For a deeper discussion of recent legislative and regulatory activity, watch US-Rx Care’s PBM reform webinar.
Reform may continue changing the requirements surrounding pharmacy benefits. Employers and health plans do not need to wait to ensure complete fiduciary alignment with their pharmacy benefit manager.
Find problems hidden in your PBM contract with the Contract X-Ray tool.
Review your PBM contract with US-Rx Care and identify where stronger fiduciary alignment may be needed.