Increased Scrutiny of Health Plans Leaves Advisers Racing to Keep Up
As federal regulators tighten their grip on the opaque world of prescription drug pricing, a new wave of rules is forcing employers, advisers and benefit consultants to rethink how they oversee health plans—and how much they really know about the intermediaries who run them.
At the center of the shift are pharmacy benefit managers—who negotiate drug prices, design formularies and process claims for employer-sponsored health plans. Long criticized for hidden fees and complex rebate structures, PBMs are now the focus of sweeping transparency requirements from both Congress and the Department of Labor.
The result is a fast-evolving compliance landscape that many advisers say is beginning to resemble the regulatory overhaul of retirement plans more than a decade ago—and may prove just as disruptive.
“If you haven’t already focused on your fiduciary processes, now is the time to do it,” said Kim Wilcoxon, a partner in Thompson Hine LLP’s employee benefits practice, during a March 18 company webinar on the new PBM rules.
As for what to do, Dae Lee, a former pharmacist who now co-chairs the PBM and pharmacy practice at law firm Buchanan Ingersoll & Rooney, says plan sponsors should move to vet their PBM contracts imminently.
Lee, who advises plan sponsors and independent pharmacies on PBM contracts and drug pricing, says any inaction risks future litigation risk.
Plan sponsors “should review their current contracts, tighten the loopholes, audit the PBM performance and ensure that the PBMs are acting in the best interest of the plan,” Lee says.
Transparency Push Gains Momentum
PBMs have long been under scrutiny, but Congress has only recently intensified its examination of these firms. In 2024, the House Committee on Oversight published a report on the rising cost of health care, casting blame on the three largest PBMs: CVS Caremark, Express Scripts and OptumRx.
The Federal Trade Commission in 2024 later sued several PBMs for allegedly inflating insulin prices. As of March 2026, Express Scripts had finalized a sweeping consent order, CVS Caremark had reached a proposed settlement pending FTC approval and Optum Rx remained the sole holdout with the case stayed while settlement talks continued.
Now, regulators have brought new rules.
In January, the Department of Labor proposed a rule requiring PBMs and affiliated consultants to disclose detailed information about their compensation to plan fiduciaries. The rule’s goal is to give employers the tools to assess whether the fees they are paying are reasonable and in the best interest of workers.
The proposal builds on provisions embedded in the sprawling Consolidated Appropriations Act of 2026, which includes new health care transparency requirements aimed at curbing hidden revenue streams in the drug supply chain.
Together, the measures reflect a relatively bipartisan push to shine light on a system that has grown increasingly complex and costly. PBMs, which operate at multiple points in the pharmaceutical supply chain, can earn revenue through administrative fees, spread pricing and manufacturer rebates—often without full visibility to employers or plan participants.
“We’re now importing a disclosure-oriented world” of health benefits, says Andrew Oringer, general counsel at the Wagner Law Group. He adds that once plan sponsors understand compensation flows, they can start to question whether the deal they are getting is a good one.
From Retirement Plans to Health Plans
For many advisers, the shift feels familiar.
Sean Kelly, a financial adviser at Heffernan Financial Services, compares the current moment to the overhaul of retirement plan fee disclosures under the Employee Retirement Income Security Act. Back in the 2010s, hidden revenue-sharing arrangements were brought into the open, reshaping how plans were priced and managed.
“We’ve seen this movie before,” Kelly says. “Everything became fully disclosed, and that changed behavior. This feels like a similar situation.”
Like retirement plan sponsors before them, employers offering health benefits are increasingly being treated as fiduciaries—responsible for acting in the best interests of employees and understanding how service providers are paid.
Employers have already faced lawsuits alleging that they allowed PBMs to profit at the expense of plan participants. For example, both Gluesing v. Prudentrx LLC & Caremark RX LLC, filed in December 2024, and Gurwitch v. Save on SP LLC et al., filed in January 2025, assert that PBMs are ERISA fiduciaries and seek to hold them accountable for breaching their fiduciary duties.
What Employers Must Do Now
For plan sponsors, the immediate challenge is practical: figuring out how to comply.
Jamie Greenleaf, a benefits consultant who co-founded the firm Fiduciary In A Box, says employers should begin with a close review of their PBM contracts—particularly provisions related to rebates and pricing spreads.
“The first thing they need is to review their contracts,” Greenleaf says. “[They need to] understand what’s going on with rebates and spread pricing, then insist on transparency if the PBM wants to continue doing business.”
In some cases, that may mean going out to bid. New rules can give employers leverage to renegotiate terms or replace vendors altogether, she says.
But experts caution that transparency alone will not eliminate complexity. PBMs, like other financial intermediaries before them, may adapt their business models in response to new rules.
“Nobody wants to see their revenue models shrink,” Greenleaf says, adding that PBMs will likely reshuffle how they profit. The difference now is employers should be more sophisticated and should ask better questions.
Advisers Step In
For retirement plan advisers, the changes present both an opportunity and a challenge.
Most are not expected to become experts in pharmaceutical pricing. Instead, their role is increasingly that of a facilitator—helping plan sponsors understand the issues and connecting them with specialists.
“I don’t think it’s the adviser’s job to explain every detail,” Kelly says. “But it is our job to make clients aware and bring in the right experts.”
Experts might include benefits attorneys, consultants or brokers who can interpret overlapping rules from multiple agencies and translate them into actionable steps.
Advisers are also encouraging clients to focus on fiduciary basics—understanding who is being paid, how much and for what services—and ensuring those arrangements can be justified.
“At its core, fiduciary duty means acting in the best interest of your employees,” Kelly says. “Right now, that means understanding the money flows.”
A Market in Transition
Over time, experts expect the market itself to adjust.
As disclosure requirements become standard, PBMs and consultants may begin offering simpler, more transparent pricing models to remain competitive. That pattern played out in the retirement plan industry, and fee disclosures eventually led to more standardized and negotiable arrangements.
Still, the transition is unlikely to be smooth. The pharmaceutical supply chain remains one of the most complex segments of the health care system, involving manufacturers, wholesalers, pharmacies, PBMs and insurers—each with its own incentives and revenue streams.
While regulators are focused on transparency, they are not setting prices or dictating outcomes. The burden of acting on the new information will fall largely on employers and their advisers.
For now, advisers say the best strategy is simple: stay informed, ask questions and be proactive. That includes educating clients about the new rules, reviewing contracts and, when necessary, bringing in outside expertise. It also means recognizing that health care—long treated as a separate silo from retirement planning—is becoming an integral part of fiduciary oversight.
“This is coming up more than it ever has,” Kelly says. “Even if clients aren’t asking yet, we’re starting the conversation—because it’s only going to get bigger from here.”