New Pharmacy Benefit Manager Rules Shift Focus to Verifiable Accountability

New federal transparency requirements for pharmacy benefit managers (PBMs) are poised to fundamentally change how the industry demonstrates compliance. Rather than simply reporting pricing and rebate data, the new rules require pharmacy benefit operations to prove, at the claim level, how financial outcomes were generated.

The new mandates, described in a Tuesday (July 14) MedCity News analysis by Lori Daugherty, CEO of PBM RxLogic, stem from transparency provisions included in the Consolidated Appropriations Act of 2026 and related Department of Labor proposals affecting employer-sponsored health plans. Together, they establish a framework that requires PBMs to produce structured, repeatable and machine-readable evidence showing how prescription drug pricing, rebates and payments are calculated.

According to the analysis, the reforms reflect years of growing concern over rising prescription drug costs and longstanding criticism that employers lacked sufficient visibility into the financial practices of PBMs. Federal investigations identified spread pricing, pharmacy steering and rebate arrangements as key areas of concern, prompting Congress to impose new disclosure obligations.

Among the most significant requirements is a mandate that PBMs disclose the difference between what health plans pay PBMs for prescription drugs and what PBMs ultimately reimburse pharmacies. But the MedCity analysis argues that regulators are now seeking far more than raw pricing information.

Instead, the new regulatory approach requires PBMs and group health plans to provide transparent explanations that can consistently demonstrate how pricing decisions and financial results were reached. For self-insured employers, the Department of Labor has proposed clarifying under the Employee Retirement Income Security Act (ERISA) that plan fiduciaries will be expected to use those disclosures to determine whether PBM compensation is reasonable under the new transparency framework.

That marks what the analysis described as a shift from asking whether data exists to determining whether organizations can verify how reported outcomes were produced.

To meet that standard, PBMs will need systems capable of generating recurring machine-readable reports while providing claim-level visibility into pricing, rebates and payments. Required reporting includes gross and net drug costs, rebates, fees, discounts, utilization data and pricing information tied to individual claims. Rather than simply producing aggregate financial summaries, organizations will be expected to reconcile each component of a transaction and explain how it contributed to the final result.

The transparency requirements also extend to patient and plan spending. PBMs must disclose total participant out-of-pocket costs and total net spending for individual drugs, enabling regulators, employers and plan fiduciaries to evaluate the financial impact of PBM practices more comprehensively.

Daugherty’s analysis argued that these requirements expose shortcomings in many legacy PBM technology platforms, which historically emphasized transaction processing while relying on spreadsheets, downstream reporting tools and manual audits to satisfy transparency obligations. Those systems often cannot reconstruct pricing logic, trace rebate flows or reconcile financial outputs in a way that regulators can independently verify.

Under the emerging framework, transparency must instead be embedded directly into operational workflows. PBMs will need to maintain continuous claim-level traceability spanning pricing methodologies, rebate governance and financial reconciliation. They also must track and report wholesale acquisition costs for brand-name drugs and average wholesale prices for generic medications, allowing regulators to validate pricing decisions throughout the claims process.

The reporting provisions are scheduled to take effect 30 months after enactment of the federal law, providing PBMs time to modernize their operational infrastructure. But Daugherty argued that the reforms represent a lasting structural shift rather than a temporary compliance exercise.

Ultimately, the new transparency regime is designed to replace trust-based oversight with continuous verification. According to the analysis, organizations capable of embedding traceability, audit readiness and compliance logic directly into their claims-processing systems will be better positioned to satisfy regulators, employers and plan fiduciaries as PBM oversight enters a new era focused on demonstrable accountability rather than disclosure alone.