When we meet with employers, one theme consistently surfaces across every conversation: the recent PBM legislation was a major step in the right direction – finally.
For years, employers have managed their pharmacy benefit programs with one hand tied behind their backs. Obscure contracts, perverse incentives, and complex rebate structures turned what should be a straightforward relationship into an employer’s nightmare. Now, a wave of federal action is changing that dynamic—giving employers the leverage, the data, and the regulatory backing to demand a fair deal.
Taken together, these reforms do three important things: they set clearer expectations for how PBMs will operate in the coming years, they expand what employers can see and verify in contracting and claims, and they elevate disclosure from a “nice-to-have” into an enforceable requirement. The result is a more level playing field – one where employers can negotiate based on total cost, transparency, and accountable performance rather than opaque guarantees.
Now the question is: how will employers use it?
Every benefits director knows the annual rhythm: renewals, rebate promises, market checks, a few benchmark slides, rinse and repeat. But as the U.S. Department of Labor (DOL) oversight (pending public comment and final rulemaking) expands and PBMs are designated as covered service providers under ERISA, the traditional renewal cycle no longer works. Employers can and must step beyond “negotiated discounts” and dive more into evaluating PBMs on performance transparency and clinical outcomes.
The opportunity is not just to renegotiate a contract. It is to rethink and restructure the PBM relationship entirely.
New Employer Levers
For employers, the most immediate shift is financial: full rebate pass-through is no longer optional. Under the Consolidated Appropriations Act of 2026, plans are positioned to require 100% of manufacturer rebates and other price concessions to be returned to the plan, removing a long-standing source of hidden margin and making “we’ll share the savings” an outdated contracting posture. That change alone reshapes negotiations, because it narrows the space for opaque dealmaking and forces PBMs to compete on services, performance, and measurable value instead of retained spread.
Transparency also becomes enforceable, not aspirational, through expanded audit rights. Employers can more clearly designate independent auditors without PBM-imposed constraints and gain ERISA-aligned access to the underlying financial mechanics. They can finally see how claims are adjudicated, where fees are applied, and how revenue is generated across the channel. In practice, that means employers can validate where every dollar flows, from manufacturer rebates to specialty-drug markups and any administrative charges that previously hid in the fine print.
Finally, compensation disclosure requirements put fiduciary accountability on paper. With PBMs required to disclose direct and indirect compensation, employers can evaluate true net cost, identify conflicts of interest, and document prudent oversight with far less reliance on assurances and summaries. As DOL oversight expands, incomplete or unclear disclosure is no longer merely a negotiating issue, it becomes a compliance risk. This raises the bar for governance and strengthening the employer’s hand at renewal.
These reforms do not just level the field as some have said – for many employers, they are finally being handed the rulebook.
Disrupting the Cycle
With new transparency and accountability standards taking hold, benefit leaders have a chance to turn “disruption” into a practical playbook. The point is not to react to policy change with more complexity; it is to use the new rules to redesign the PBM relationship with clearer expectations, measurable performance, and stronger governance.
Start by shifting sourcing decisions from rebate optics to value. That means evaluating therapies based on the outcomes they produce and the total cost of care they influence, and negotiating for performance – such as adherence, net cost per therapy, and member experience – rather than relying on broad “discount” narratives. In parallel, take a hard look at specialty management, where most trend now concentrates; unbundling specialty services and considering best-in-class carve-outs can reduce conflicts and align fees to a flat-rate or performance-based approach.
Next, use the new disclosure and audit information as an operating tool, not a binder on a shelf. Build simple PBM performance dashboards that connect what is being disclosed to the plan’s KPIs (e.g., utilization, cost per claim, specialty trend, rebate recovery) and use those metrics throughout the year, not just at renewal. Finally, don’t do this work in isolation: employer-led coalitions can accelerate learning, provide benchmarks and policy intelligence, and amplify purchasing power so employers can negotiate as true fiduciaries of their plan members’ dollars.
At National Alliance, we are not just responding to reform – we are shaping a blueprint for what employer-led accountability looks like.
Employer-led coalitions have always been the disruptors: educating, influencing, and amplifying the voice of the employers designing and financing healthcare benefits for their employees. As we shift to this new era of PBM reform, coalitions can be the real differentiator – assisting employers to transition implementing and working within the new parameters set by changing rules that give employers new levers of control.
Employer Call to Action
Federal reform may set the stage, but disruption only happens when employers act. The next contracting season we need to ensure employers create positive disruption based the opportunities handed to them by legislative changes. It is not just about another renewal season – it is about rewriting of contract, practices, and governance.
So, as we embrace this new era of transparency, let’s collectively shift our mindset to one that is intentional and challenges the status quo. Employers have the data, the rights, and the voice – now is the time to use all three.