Ep. 4 - Health Care Headlines LIVE at the 2026 Annual Benefits Forum

The 2026 Benefits Forum highlighted how a two‑decade shift—from modest rebates and simple formularies to specialty‑driven spend and biosimilar competition—has reshaped pharmacy benefit management. Plan sponsors now juggle federal mandates, state statutes, and rapid technological change, all while trying to keep employee costs predictable. This backdrop explains why the Consolidated Appropriations Act (CAA) is a watershed moment: it obligates PBMs to pass 100% of rebates, demand granular drug‑level reporting, and require annual participant disclosures, with penalties reaching $10,000 per day for non‑compliance. The law’s 30‑month rollout, effective for most plans in 2029, forces employers to upgrade data pipelines and renegotiate contracts now.

Simultaneously, the FTC’s proposed settlement with Express Scripts introduces structural reforms that could lower list‑price inflation. By delinking PBM compensation from list prices, moving to cost‑plus pharmacy payments, and on‑shoring its GPO, the settlement aims to eliminate spread pricing and increase transparency. It also mandates that rebates be applied at the point of sale and eliminates guaranteed rebate contracts, shifting fee structures toward explicit service charges. These changes promise clearer pricing signals but also signal that PBMs may introduce new fee categories to offset lost spread revenue, a shift plan sponsors must model in their budgeting.

State‑level interventions add another layer of complexity. Laws like Ohio’s HB192 require minimum reimbursement at acquisition cost and a $12 dispensing fee, extending to all network pharmacies and often pre‑empting ERISA plan design. While courts have limited state authority over network design, reimbursement mandates persist, creating a patchwork of compliance obligations. Direct‑to‑consumer platforms such as TrumpRx further complicate pricing, as pharmacies are not obligated to honor advertised coupons, leading to reimbursement gaps. Employers should therefore prioritize robust contract language, real‑time rebate analytics, and proactive engagement with PBMs to navigate federal, state, and market pressures while safeguarding employee benefit affordability.