New rules and laws reshape how employers work with PBMs. Three major developments:
A. Proposed Rule (Effective for plan years starting July 1, 2026)
Self-insured ERISA plans must:
- Obtain and review PBM compensation disclosures each year before signing or renewing a contract.
- Receive a semiannual explanation if PBM compensation is 5% or more above the original estimate.
B. New Federal Law (Effective for plan years starting August 3, 2028)
All group health plans will see changes. Requirements include:
- PBM reporting for large plans (100+ employees)
- New PBM notices and summaries for all plans
- Passthrough of all non-transparent PBM compensation in ERISA plans
C. FTC Enforcement
The FTC reached a settlement with Express Scripts requiring business practice changes that affect employer plans. The FTC has similar cases underway involving Caremark Rx and OptumRx.
What this means for employers:
- Every employer offering Rx coverage will be affected.
- ERISA plans must review PBM disclosures as part of their fiduciary duties.
- A new employee notice begins in late 2028, with a $10,000/day penalty for failure to provide it.
- Start preparing internal procedures now to review PBM compensation for reasonableness and conflicts of interest.
COMMENTS