BENEFITS DIGEST

Writing for benefits brokerage Borislow, Sena Meilleur argues that smaller employers can no longer treat renewal season as the moment to manage catastrophic claim risk. GLP-1 pharmacy spend, cell and gene therapies that can cost more than $1 million per claim, and AI-driven coding intensity are reshaping medical budgets, so the useful decisions, about self-funding, captives and reinsurance against the biggest claims, happen early in the plan year, before an adverse claim limits the options. She treats a good renewal as a signal to dig in rather than coast.

Employers buying Medicare coverage for retirees would have another set of contract and network requirements to consider under this CMS proposal. Medicare Part D pharmacy benefit managers would have to pass through the full amount of manufacturer discounts and rebates and operate under new compensation restrictions. Medicare Advantage plans would face provider-directory checks and protections for members who rely on inaccurate listings when scheduling care. Most requirements would begin in 2028, with the first annual PBM reports due July 1, 2028 for the prior year. Comments close December 15 at 5 p.m. Eastern. This proposal concerns Medicare products, separate from Labor’s employer-plan PBM disclosure initiative.

Medication costs can show up in retirement savings. Among GLP-1 users surveyed by Nationwide, 14% reported withdrawing retirement money, 14% reported reducing contributions and 17% reported taking on new debt. 51% worried about trading retirement security for the medication, even as 88% remained optimistic about its health benefits. These self-reported findings don’t establish that the drugs caused the financial changes. They do give health and retirement teams a shared issue to examine when assessing employees’ out-of-pocket costs.

OIRA’s docket shows the Labor Department’s rule titled Improving Transparency into Pharmacy Benefit Manager Fee Disclosure concluded review on October 20 and cleared with changes made during the review, which the docket records as consistent with change. The [January proposal](https://www.federalregister.gov/documents/2026/01/30/2026-01907/improving-transparency-into-pharmacy-benefit-manager-fee-disclosure) would require disclosure of the direct and indirect compensation pharmacy benefit managers receive, so that group health plan fiduciaries can judge whether their PBM contracts are reasonable, and the rule’s [Unified Agenda entry](https://www.reginfo.gov/public/do/eAgendaViewRule?pubId=202510&RIN=1210-AB37) carries the fuller description. The cleared text is not yet public, so what the rule now says awaits Federal Register publication.

KFF’s annual benchmark survey, published October 22, puts the average family premium at $28,303, up 5% from 2025, with workers contributing $7,471 of it, up 9% or $621. Single coverage averages $9,804 with workers paying $1,672, and among workers whose plans have a general annual deductible, the average for single coverage is $1,955. The [announcement](https://www.kff.org/private-insurance/workers-now-pay-7471-on-average-annually-for-family-health-coverage-up-9-or-621-from-2025-benchmark-employer-health-benefits-survey-finds/) highlights the cost shifting behind the worker numbers, with 44% of large employers, those with 200 or more workers, reporting they increased the share of premiums workers pay. Among those large firms, 18% cover GLP-1 drugs for weight loss, essentially flat from last year.

Healthcare Dive’s report adds reporting context to the Medicare Advantage and Part D proposed rule published in the October 20 Federal Register, including the enforcement history behind the directory-accuracy push and reaction from the PBM side. The proposal would hold enrollees to in-network cost sharing when inaccurate listings mislead them and would restrict Part D PBM compensation to flat service fees. It remains a proposal, with comments due December 15, and its direct reach is Medicare arrangements rather than commercial self-funded plans.

CMS proposes requiring Medicare Advantage plans to verify provider directories every 90 days, to hold enrollees to in-network cost sharing when an inaccurate listing misleads them, and to report accuracy information that would later become public. On the drug side, the proposal would restrict Part D PBM compensation to flat fair-market-value service fees, require rebate pass-through and disclosures, and eliminate certain generic copayments for low-income dual-eligible enrollees starting in 2028. The [fact sheet](https://www.cms.gov/newsroom/fact-sheets/medicare-program-implementation-sections-6219-6220-6224-consolidated-appropriations-act-2026-cms) carries the details, and different provisions carry different dates. For plan sponsors the direct reach is employer-group Medicare arrangements rather than commercial self-funded plans, and comments on the [proposed rule](https://www.federalregister.gov/d/2026-21420), published in the October 20 Federal Register, are due December 15.

Aon’s 2026 Human Capital Trends Study projects the North American gross medical trend easing to 9.2% in 2027, the first time in five years the region’s forecast has come in below the prior year’s, and finds 87% of responding organizations planning to use well-being initiatives next year. Aon’s Kathryn Davis cautions in an accompanying interview that moderation is not relief, since costs keep rising from an elevated base while aging populations, chronic conditions and new treatments push the other way. She frames GLP-1 coverage as a question of access, clinical appropriateness and the whole employee health journey rather than a standalone pharmacy decision, and urges targeted, data-driven cost management over across-the-board cuts.

Troutman Pepper Locke previews an October 29 conference session in Dallas where Laura Ferguson and Dr. Dominic Vu will take up PBM reform, pharmacy transparency and the questions employers should be putting to their pharmacy benefit managers. The page is an event announcement with logistics rather than analysis.

A promise to pass through all rebates doesn’t necessarily capture every payment a pharmacy benefit manager receives from manufacturers. In a newly posted reprint from the second-quarter Benefits Quarterly, Segal’s Edward Kaplan examines how contract definitions, pricing exclusions and reconciliation terms can change the economics of a pharmacy benefit deal. Sponsors should look beyond headline discounts to the drugs and claims those discounts cover, the treatment of generic pricing, and fees or offsets that can dilute a guarantee. The article also considers formulary and clinical management choices. Its contracting advice is a reason to compare the complete arrangement and monitor actual performance, not to assume that a larger rebate or a particular cost-sharing design always produces better value.

A Health Transformation Alliance analysis of linked health records and claims identifies patient characteristics associated with stronger responses to GLP-1 drugs. Employee Benefit News reports that the research draws on a 12.7 million-patient sample and examines blood sugar and weight outcomes. HTA CEO Rob Andrews argues that employers should ask whether treatment produces lasting health improvements, rather than judging coverage solely by prescription spending. He also draws an important limit. Patterns across populations can’t reliably predict whether an individual will respond and shouldn’t replace decisions between patients and their doctors. Longer-term healthcare cost effects remain uncertain. The findings offer questions for evaluating a coverage program, not a ready-made set of eligibility restrictions.

A GlobalData Healthcare and Omada report projects greater medical savings for GLP-1 users who remain on treatment longer, but the figures exclude the drugs’ cost and the price of Omada’s lifestyle program. EBN reports that the model uses data from 24,595 commercially insured Omada members who took a GLP-1 for at least six months and compares them with a modeled scenario without either intervention. Projected five-year medical savings reach $8,578 per member for the group treated at least six months and $11,142 for those treated at least a year. These are modeled savings, not five years of observed net savings for employers. Omada’s chief medical officer argues for evaluating health risks beyond weight and helping patients sustain clinically appropriate treatment.

Reaching a target weight shouldn’t automatically end GLP-1 coverage, argues Dr. Tim Church, Wondr Health’s chief medical officer. His EBN commentary describes obesity as a chronic condition and warns that stopping successful treatment can bring weight regain and renewed health risks. He urges employers to examine who makes discontinuation decisions, what support patients receive afterward and whether the program tracks outcomes beyond short-term weight loss or pharmacy spending. Church doesn’t argue that everyone needs medication indefinitely. He favors individualized clinical decisions supported by behavioral care. His case for continued treatment is a vendor medical officer’s policy argument, not proof that keeping every patient on a GLP-1 will reduce an employer’s total costs.

Nationwide Retirement Institute’s 2026 Healthcare Costs Survey quantifies a tradeoff benefits teams have sensed. Among current GLP-1 users, nearly half worry the drugs’ cost is eroding their retirement savings. Fifty-four percent have changed financial behavior to afford the medications, including 17 percent taking on debt and 14 percent each withdrawing from savings or trimming retirement contributions. Out-of-pocket costs average $203 a month for users whose insurance does not fully cover the drugs. Among surveyed GLP-1 users, 88 percent feel better about their long-term health, and 64 percent say they may retire later because of it. But 59 percent doubt they can afford the medications in retirement.

KFF’s annual explainer lands ahead of Medicare open enrollment, which runs October 15 through December 7. Beneficiaries with employer or union retiree coverage can lose it permanently by switching between traditional Medicare and Medicare Advantage, because many employers offer retiree benefits exclusively through one or the other. Sixty-five percent of beneficiaries did not compare options during the last enrollment period. For 2027, the average beneficiary will have 35 Medicare Advantage plans to choose from. On the drug side, the Part D out-of-pocket cap reaches $2,400, and the new GLP-1 Bridge Program offers $50 monthly copays for weight-loss coverage outside Part D. The brief also notes that roughly 32,000 current beneficiaries are set to lose eligibility starting in 2027 under the reconciliation law’s immigration provisions.

EBRI and Greenwald Research surveyed 1,238 workers ages 21 to 64 in late June and July for the seventh annual edition of this survey. Concern eased slightly across every well-being measure, with financial worry at 6.0 on a 10-point scale, down from its 2022 high of 6.9, yet 70 percent of workers report problematic debt and 57 percent say they often or always feel sick at work. Workers pointed to retirement plans and health insurance as their leading sources of financial security, at 64 and 63 percent, while only 52 percent are very or extremely satisfied with their benefits package and 45 percent name a bigger employer contribution as the most valuable improvement. Two findings deserve a benefits manager’s attention. A quarter of insured workers now say their plan covers GLP-1 drugs for weight loss, up from 16 percent last year, and 45 percent agree employers should cover them. And on AI, 71 percent are concerned about bias in AI tools used for benefit recommendations, while given the choice only 15 percent would pick an AI-powered benefits counselor over a human one.

The Seventh Circuit upheld an Arkansas rule requiring health plans to disclose pharmacy compensation and cover dispensing fees when a pharmacy benefit manager or another intermediary underpays a pharmacy. The multiemployer fund behind Central States v. McClain, suing in Illinois federal court, argued that ERISA preempted the rule. The court concluded that the payment requirement regulates costs and that the reporting requirement does not intrude on the central administration of an employee benefit plan. Self-funded plans operating nationally now have one more state PBM rule the courts have let stand.

Ben Conner, who leads the benefits brokerage Conner Insurance, argues that rebates and changes to drug coverage don’t address the underlying conditions driving pharmacy spending. Conner says his diabetes playbook, standalone clinics, home-delivered medications and incentives for working with health coaches, held per-patient costs steady and cut emergency visits and admissions. Mental health is his next target, and the obstacle is measurement. Some newer specialty psychiatric medications run $15,000 to $20,000 or more per member a year, utilization keeps climbing, and unlike diabetes there’s no A1C, no lab value that shows a drug is working. Conner argues that continued prescription use can become a substitute for measuring whether treatment helps, and that the incentives point the wrong way, since pharmacy benefit managers and manufacturers are paid when prescriptions keep filling. He is explicit that the answer isn’t denying care. He wants employers to ask what evidence shows that expensive medications, together with clinical support, are actually improving patients’ lives.

The Sixth Circuit has overturned an order that let roughly 800 plaintiffs in the national opioid litigation add claims against pharmacy benefit managers affiliated with OptumRx and Express Scripts nearly two years after the deadline to amend their complaints. In an October 2 order in In re OptumRx, the appeals court said the judge who manages the litigation, Dan Polster, clearly abused his discretion by finding good cause for the delay across the board instead of examining each plaintiff’s explanation, and it noted the PBMs’ point that some plaintiffs had sued them as early as 2018. The court granted the PBMs’ petition for a writ of mandamus, the rarely used order that corrects a trial court midstream, vacated the amendment order, and directed the district court to look at diligence plaintiff by plaintiff. The claims aren’t dead. Amendments backed by actual diligence can still go forward.

Segal analyzed claims from large employer health plans covering more than four million people. Among patients with diabetes in those plans, nearly half now take Mounjaro, Ozempic or another GLP-1. Since January 2021 the share using insulin has been cut almost in half, metformin use has dropped 17 percentage points, and fewer than 2% still take DPP-4 inhibitors. As treatment guidelines move GLP-1s earlier, prescribers are taking patients off the older, cheaper drugs, which is part of what plan sponsors are seeing in their prescription drug costs.

The third installment on brokerage consolidation turns to conflicts of interest. When the brokerage, carrier, pharmacy benefit manager, claims administrator, and stop-loss carrier are owned by or economically aligned with the same enterprise, the article argues, common ownership can weaken the independent oversight that catches overpayments and unfavorable terms. As one consultant puts it, the conflict is structural, built into the organization chart before a single decision gets made. The article ties the scrutiny directly to the recent wave of ERISA fiduciary suits over medical claims, drug pricing, and voluntary benefits.

CMS wants comments on what a fair pharmacy contract looks like. A new request for information begins implementing a 2026 budget law amendment that requires the Secretary to set reasonable and relevant standards for the contracts Part D plans and their pharmacy benefit managers offer pharmacies, standards due by April 2028 and applying to plan years starting January 1, 2029. The questions reach well beyond Medicare mechanics: whether pharmacies are paid more or less than drugs cost them to buy, pricing guarantees measured across all drugs rather than drug by drug, whether Medicare contracts subsidize PBMs' commercial business, discounts under the federal 340B drug pricing program, which drugs get labeled specialty drugs, and what happens when the PBM and the pharmacy share an owner. Employer plan sponsors have seen every one of those issues in their own PBM negotiations, and standards CMS writes for Part D have a way of becoming the reference point for the commercial market. Comments are due November 23, 2026.

The Seventh Circuit upheld an Arkansas rule requiring pharmacy benefit managers to pay pharmacies fair and reasonable rates. Mintz explains why the court treated that payment rule differently from state laws governing pharmacy networks: the Sixth, Eighth, and Tenth Circuits have struck down laws that reached network design and preferred-pharmacy structures, while the Arkansas rule regulates only what pharmacies are paid. The court separately held that the data reporting needed to enforce a lawful payment rule does not run into federal limits on state reporting requirements. Self-funded plans operating nationally now face one more state PBM rule that courts have let stand.

Milliman puts numbers on a question more sponsors are asking, whether to move from traditional drug rebates, money the pharmacy benefit manager returns to the plan months after prescriptions are filled, to models where the discount is applied at the pharmacy counter. Comparing the two on annual cost alone makes rebates look better than they are, because during a transition the plan still collects prior-year rebates while paying lower net prices, and a dollar of discount today is worth more than the same dollar returned months later. Under the authors' assumptions, a net price model is worth about $1.25 per member per month to the plan sponsor compared with a traditional rebate arrangement, with members gaining through lower cost sharing on brand and specialty drugs. For sponsors with rebate-dependent budgets, the transition math is the part worth handing to the consultant.

New transparency reporting is giving employers a clearer view of how their pharmacy benefits actually work. On Marsh's podcast, Jennifer Calhoun Mohl talks with Jon Lewis of the firm's pharmacy practice about what the data is beginning to show about spread pricing, the difference between what a pharmacy benefit manager charges a plan and what it pays the pharmacy, and about rebates the PBM keeps rather than passes through, and what employers might do with that information when reviewing pharmacy benefit strategy and contracts.

Quarles recommends preparing for California's five health-care AI bills together, with an inventory of AI tools and procedures for human oversight, disclosure, and consent. The measures address clinical decisions, bias in decision-support tools, protection for clinicians who override AI, psychotherapy, and access to human customer-service agents. The chatbot bill, AB 1609, still awaits the Governor's signature. Quarles urges organizations to prepare for potential January 1, 2027 requirements. Health plans and pharmacy benefit managers serving California members should review their chatbots and vendor contracts.

Patients have sued Novo Nordisk and Eli Lilly, alleging that the companies failed to warn about a rare optic-nerve condition that can cause sudden, sometimes permanent vision loss. The consolidated proceeding in the Eastern District of Pennsylvania had more than 130 cases as of this summer. The companies deny the allegations and dispute causation. Separately, Europe's medicines regulator classified the condition, NAION, as a very rare side effect of semaglutide in 2025. It estimated about one additional case per 10,000 people treated for a year.

Several major benefits rules are awaiting White House review, the last stop before publication. EBSA's automatic portability exemption arrived September 14 as a final rule with a statutory deadline. Its PBM fee disclosure transparency rule has been there as a final since July 23. Treasury sent two Trump Accounts rulemakings on September 18, an interim final rule and a companion proposal under new section 530A. And Treasury's final rule on automatic enrollment under section 414A has been in review since June.

In Commonwealth of Kentucky v. Express Scripts, No. 25-5866 (6th Cir. Sept. 18, 2026), Chief Judge Sutton reversed a remand and kept Kentucky's opioid suit against Express Scripts and Optum in federal court under the federal officer removal statute. The PBMs negotiate formulary placement and rebates for federal employee, TRICARE, and veterans programs alongside their commercial book, and the court found “little to no daylight between their federal and non-federal conduct” because they conduct a single negotiation for all clients. Kentucky's attempt to disclaim the federal side of that indivisible conduct didn't work, a result the opinion counts five circuits reaching. Among the colorable federal defenses: ERISA preemption of claims aimed at how a PBM structures its standard formulary offerings. The decision concerns where Kentucky's lawsuit will proceed, not whether the PBMs are liable. But the structural fact that drove it, one negotiation serving federal and commercial plans alike, is the same feature at the center of the PBM transparency debates sponsors are living through.

Weight-loss drugs are the single largest contributor to the record increase in employer health-insurance costs expected next year, the Post reports, and the retreat has begun. PepsiCo stopped covering the drugs for non-diabetic employees; Cigna dropped them for its own workforce. In a Business Group on Health survey, two-thirds of companies still cover weight-loss drugs but 10 percent plan to stop in 2027, and a separate Marsh analysis finds 27 percent adding restrictions such as minimum BMI thresholds or a sleep apnea or cardiac diagnosis. Fully insured employers may not get a choice at all if carriers refuse to price the coverage. For workers, the difference between employers is personal: one worker now pays $450 a month for Zepbound, eating up more than a third of the $15,000 raise she received when she switched to a job that did not cover the drug. EBN's companion piece cites an estimate from digital weight-loss clinic Embla Health that employers pay $600 to $900 a month after rebates for each person taking the drugs, and actuary Amanda Turcotte offers a practical caution: supporting treatment does not have to mean paying every dollar, but switching coverage on and off each year risks hurting employees' health and morale.

What can a smaller employer do when traditional health insurance gets too expensive? Foley walks through the alternatives: level-funded plans and captives, which self-fund claims with insurance protection against large losses; association plans and professional employer organizations, which band employers together; and ICHRAs and QSEHRAs, accounts that help employees buy their own coverage. Other approaches change where employees receive care or how providers and pharmacies get paid, from narrow networks and virtual-first designs to direct primary care and GLP-1-specific reimbursement accounts. There are plenty of choices but no universal bargain: each option trades premium savings for financial risk, administrative work and compliance obligations the employer takes on.

Arkansas has required pharmacy benefit managers to reimburse pharmacies at least the national average acquisition cost of a drug since 2015; a law passed last year finally gave pharmacies the right to sue over violations, with statutory damages up to $10,000 per violation. Twelve independent Arkansas pharmacies have now become the first to use it, filing in Missouri state court, Express Scripts' home turf. They say they documented about 48,300 underpaid prescriptions between August 2025 and March 2026, likely an undercount given their limited view into claims data, and the complaint does not mince words: “Express Scripts' failure to comply with Arkansas law is not a technological challenge; it is a business decision.” Express Scripts says it pays competitive rates and will defend itself. One to watch for plan sponsors as states keep building private enforcement mechanisms against PBMs.

Health plan governance is getting the 401(k) treatment. Benefits attorneys and consultants walk through what sponsors should be doing now: negotiate rebate pass-throughs and oversight rights into PBM contracts before signing, benchmark per-member fees, and collect compensation disclosures from every vendor taking $1,000 or more a year from the plan. The clock behind the advice is the Consolidated Appropriations Act of 2026. Its ERISA-fiduciary provisions treat PBMs as covered service providers and require spread pricing out of contracts by August 1, 2029.

Part two puts numbers on the insurer's share: overhead and profit run about $846 per enrollee per year in the employer market, $987 in the individual market, and $1,655 in Medicare Advantage—where roughly a dime of every premium dollar stays with the plan, against under two cents of administrative cost in traditional Medicare. Margins are thin in percentage terms, but the seven largest publicly traded insurers, PBM subsidiaries included, earned an estimated $71 billion in 2024. The question posed is not whether they profit but what value comes back.

Lockton's third quarter market update names four pressures keeping costs elevated: expensive medications, accumulating high cost claims, chronic condition management, and rising utilization. On the pharmacy side it calls out double digit brand drug price increases and growing GLP-1 spend. The update pairs a five step checklist for managing increases with a look at leave administration complexity.

The court enjoined enforcement of the Prescription Drug Affordability Act's reporting requirements against PCMA members serving ERISA covered plans, finding the claim by claim disclosure mandates—drug lists, dosage units, out of pocket spending, rebate passthroughs, copies of PBM contracts—most analogous to the Vermont database law preempted in Gobeille. Last month's Seventh Circuit decision in McClain did not save the statute, because the Illinois requirements are not incidental to any fee or tax provision and reach far beyond one. Fines of $10,000 per day made the harm irreparable, relief runs association wide, and the first annual reports had been due the day after the order.

Robert Andrews, the former congressman who leads the Health Transformation Alliance, tells EBN the question for employers is not how much they spent but what they got for the money. With nearly all employers covering GLP-1s for diabetes, the hard decision is obesity coverage for patients who are not diabetic, and Andrews describes a turn toward clinically driven coverage decisions built on claims and health record data, watching whether weight stays off and A1C improves. Before cutting benefits, he argues, employers should chase the waste first, the billing errors, ineligible claims, and payments that should never have gone out the door.

Marsh's national survey of more than 1,800 employers projects health benefit costs rising 8.2% in 2027, the sharpest annual jump since 2003, and 11% for employers who take no action. Some 59% plan cost-reduction moves such as raising deductibles, and GLP-1 coverage alone accounts for about a percentage point of the increase.

This week's roundup, a short-handed edition with no case of the week, flags two decisions as most notable. In Central States v. McClain the Seventh Circuit held that Arkansas's latest pharmacy benefit manager regulation survives ERISA preemption, and in Liu v. Kaiser the Ninth Circuit extended the substantial compliance doctrine to benefit elections. The edition also collects the week's decisions on arbitration, attorneys' fees, fiduciary breach, disability claims, preemption, exhaustion, and pleading.

New Lockton data shows Texas employer health spending rising on medical prices, hospital market consolidation, and prescription drug costs even as utilization levels off.

Attorneys from McDermott Will & Schulte review the costs, benefits and risks for employers to evaluate when deciding how their benefits address these popular medications.

A deal between rival drug middlemen Prime Therapeutics and Express Scripts depressed reimbursement rates for pharmacies, according to the new complaint. It is the latest legal challenge against the partnership.

Employers face another steep rise in healthcare expenses in 2027, prompting a closer look at GLP-1 coverage, pharmacy spending and high-cost conditions.

In Larkin v. Caremark Rx, No. 1:25-cv-07307 (S.D.N.Y.), participants allege the PBM wrongfully denied coverage for the GLP-1 drug Zepbound on medical-necessity grounds while steering them to Wegovy. According to early reports, the court has now declined to compel arbitration based on an arbitration provision in CVS's website terms of use, letting the ERISA coverage claims proceed. The order itself is not yet publicly posted, and the decision date is unconfirmed.

From unexpected babies to "Ozempic teeth," the ultra-popular class of GLP-1 medications are turning out to have a few unanticipated side effects. Emerging research shows the drugs, which have proven effective in treating obesity and diabetes, may also be useful in treating addiction.

After years of arguing over what GLP-1 coverage should cost, employers are starting to ask the harder question: whether it is paying off. EBN on the early return-on-investment evidence and how benefit teams are measuring it.

We describe how employer-sponsored health plans can use audits of their pharmacy benefit managers to identify operational and performance issues and help control drug cost expenditures.

Under pressure to stay competitive while controlling costs, employers are turning new scrutiny on PBM contracts, hospital prices, and GLP-1 coverage heading into 2027 planning.

Mercer's quarterly state survey: Virginia enacted both paid family and medical leave and paid sick and safe leave, several states passed major PBM laws including a Tennessee statute challenged in court the day it took effect, and Alabama, Georgia, and Texas legislated on AI use in benefits.

A practical roundup of the coverage decision every health plan is facing: GLP-1 demand keeps climbing, the costs are reshaping budgets, and experts weigh the alternatives benefit leaders are actually considering.

Employers name high drug prices, high-cost claims, and hospital prices as their biggest affordability threats, and most say healthcare inflation is now eating directly into salary budgets. The compensation-side echo of the 10 percent trend number IFEBP put up last week.

The FTC's July settlement with Caremark resolved allegations that rebate-driven formulary practices inflated insulin list prices and patient costs. DWT draws out the plan-sponsor implications, a companion to yesterday's IFEBP settlement-terms analysis.

Recent FTC orders require Caremark Rx and Express Scripts to stop favoring high-list-price drug versions over their standard formularies. IFEBP looks at the settlement terms most relevant to plan sponsors and members.

CMS staffers intend to use the data they collect to implement new federal rules for pharmacy benefit managers serving self-insured employer health plans, an early signal for plan sponsors watching the PBM regulatory front.

Rising use of the weight-loss drugs is fueling the fastest health plan cost growth in a decade and a half, forcing employers to rethink coverage strategies and cost management.

A Milliman white paper on the GLP-1 market's dramatic growth, with U.S. spending rising from $13.7 billion in 2018 to $71.7 billion in 2023, now the largest and fastest-growing drug category. The authors examine payer coverage policies, utilization management, and cost containment, and urge payers to evaluate total cost of care, adherence durability, and long-term clinical return on investment rather than drug unit costs alone.

While multiple states have passed laws that regulate and reform policies of pharmacy benefit managers (PBMs), these laws have faced a recent deluge of legal challenges in federal court by industry groups and some plan sponsors.

ARA analysis of the JPMorgan prescription-drug fiduciary litigation, where a health plan excessive-cost suit survived dismissal in part on arguments drawn from a recent Supreme Court decision. The piece examines why a documented process may not end the inquiry when plaintiffs plead prohibited-transaction claims.

Physician and outpatient services and prescription coverage pose a significant threat to US fiscal resources, according to Boston College’s Center for Retirement Research.

As the popularity of GLP-1 medications continues to rise and the list of conditions being treated with these medications grows, plan sponsors are taking a closer look at the costs and benefits of GLP-1 coverage.

Newly released International Foundation survey data revealed key trends for glucagon-like peptide-1 (GLP-1) drug coverage for U.S. corporate employers.

“If at first you don’t succeed, try, try again” is a famous quote with unclear origins dating back over 200 years. It is a saying that plaintiff firms appear to have used as inspiration for their

Proposed rule requiring PBMs servicing group health plans to disclose direct and indirect compensation to plan fiduciaries, extending the ERISA §408(b)(2) service-provider fee-disclosure framework