Carrying forward the momentum of the Transparency in Coverage (TiC) Schema 2.0 rollout, the U.S. Department of Labor has proposed a new rule aimed at another opaque corner of healthcare finance: Pharmacy Benefit Managers (PBMs). While the initial deployment of TiC ruling was aimed at medical reimbursement transparency, this new proposed rule targets the pharmaceutical side of healthcare.
How PBMs Fit in the Greater Healthcare Landscape
At first glance, this may seem like an isolated effort; however, in practice it touches nearly every specialty. From oncology and endocrinology to cardiology and primary care, medication access, cost-sharing, and formulary decisions directly shape clinical outcomes and patient behavior.
Currently, PBMs fit into the current prescription supply chain for employer-sponsored self-insured group health plans , affecting approximately 90 million Americans today. While these functions influence both cost and access, the underlying financial arrangements are often difficult for plan sponsors and fiduciaries to evaluate.
Proposed Updates to the Current Transparency Initiative
Outlined in the proposal, are three main requirements:
- Rebates and other payments from drug manufacturers.
- Compensation received when the price paid by the plan for a prescription drug exceeds the amount reimbursed to the pharmacy.
- Payments recouped from pharmacies in connection with prescription drugs dispensed to the plan.
Direct Effect on Provider Organizations
Although this rule is directed at plan fiduciaries, the downstream effects extend to providers. Pharmacy benefit design directly influences medication affordability, adherence, and treatment access, which in turn affect utilization patterns, outcomes, and total cost of care. Greater transparency into PBM economics may ultimately shape formulary strategy, reimbursement structures, and employer purchasing decisions, creating ripple effects across clinical practice and care delivery.
Trek Health’s Role
Trek is closely monitoring the PBM proposal and preparing our data infrastructure to support rapid adoption should the rule be finalized, ensuring organizations can interpret new disclosures as soon as they become available. This potential integration of data contributes to greater visibility of the entirety of commercial reimbursement.
