Smoke and Mirrors: Why Reporting Still Falls Short in Pharmacy Benefits, and What to Do About It

In early 2026, Congress passed sweeping pharmacy benefit manager reform as part of the federal budget package. While the law includes several provisions, two stand out for employers and benefits leaders:  Mandatory 100% rebate pass-through New detailed reporting requirements These changes are designed to bring more transparency and alignment to how pharmacy benefits are managed. For employers, they create both opportunity and responsibility. Let’s break down what this means in plain terms. What Is Rebate Pass-Through? When a drug manufacturer pays a rebate, it is usually tied to a drug’s placement on a formulary or overall utilization. Historically, PBMs negotiated these rebates. But the way those dollars flowed back to employer plans was not always clear. Under the new federal law: PBMs must pass through 100% of rebates, fees, and price concessions they receive from drug manufacturers to the health plan. Rebates can no longer be retained as hidden revenue. Payments must be remitted on a regular schedule. In simple terms, the rebate dollars tied to your plan must now go back to your plan. Why This Matters Rebates have long been one of the most misunderstood parts of pharmacy benefit management. Employers often saw a rebate check but had limited visibility into: The total rebate amount negotiated Any fees retained by the PBM The true net cost of the drug after all concessions Full pass-through changes the incentive structure. Instead of revenue being tied to rebate retention, compensation shifts toward clearly defined service fees. That is a significant structural change. What About the New Reporting Requirements? The second major reform is transparency. PBMs must now provide employer health plans with detailed reporting that includes: Gross drug spend vs. net drug spend Total rebates, discounts, and fees received Spread pricing information Member out-of-pocket cost data Reports must be provided at least semiannually, and in some cases quarterly upon request. For plan sponsors who take their fiduciary responsibilities seriously, this is a big development. Why Reporting Changes Everything Data changes conversations. With more standardized reporting, benefits leaders can better answer key questions: Are we paying a fair net price? Is our PBM’s compensation aligned with our goals? Are member out-of-pocket costs improving or rising? Are specialty trends being managed appropriately? Transparency does not automatically lower costs. But it does give employers the tools to evaluate performance in a more objective way. What Employers Should Do Now Although implementation is phased in over several years, benefits leaders should begin preparing now. 1. Review Your Current PBM Contract Understand: How rebates are currently structured Whether you are already on a 100% pass-through model What reporting rights you currently have Not all “transparent” contracts are created equal. 2. Define What Success Looks Like Rebate pass-through is important. But net cost matters more.High rebates do not always equal lower overall spend. The goal should be total cost control, improved outcomes, and better member experience. 3. Prepare to Use the Data Receiving reports is one thing. Knowing how to interpret them is another. Benefits leaders may need: A standardized internal review process Independent analytics support A clearer dashboard that separates gross, net, specialty, and trend data Transparency only works if it is acted upon. The ProCare Rx Perspective At ProCare Rx, transparency has never been a trend. It has been a foundation. Long before federal reform required 100% rebate pass-through and detailed reporting, ProCare Rx built its model around: Clear rebate structures Defined service fees Straightforward net cost reporting Clinical programs that focus on total drug spend, not just rebate volume The goal is simple: align incentives with employer outcomes. Rebates matter. But real pharmacy value is measured by overall cost control, member safety, and thoughtful clinical oversight. As federal reforms roll out over the next several years, employers should not just ask, “Are we compliant?” They should ask, “Are we aligned?” Transparency is no longer optional in this industry. It is the new standard. And for employers who want to lead, not just react, this is an important moment to evaluate whether their PBM model truly supports their long-term strategy. SOURCES: https://www.sidley.com/en/insights/newsupdates/2026/02/congress-passes-significant-federal-pharmacy-benefit-manager-reform-impacting-pharmaceutical-market https://www.mintz.com/insights-cen t er/viewpoints/2146/2026-02-06-congress-passes-landmark-pbm-reform-2026-spending-bill https://hallrender.com/2026/02/05/federal-pbm-reform-is-here-unpacking-key-provisions-of-the-landmark-legislation/ https://www.sentinelgroup.com/resource-center/2026/congress-passes-pbm-reform-caa-2026

ProCare Rx Appoints Rodney Hardin as VP, Sales

When people think about pharmacy benefit managers, they usually think about drug prices, formularies, or rebates. Rarely do they think about technology. Yet behind every prescription filled at the pharmacy counter is a system working in real time to make sure the claim is processed correctly.  One of the most important parts of that system is the switch . It is not something members see, but it plays a major role in how smooth or stressful the pharmacy experience feels. As benefits leaders look ahead to 2026, understanding the role of the switch helps explain why technology decisions matter more than ever in the PBM space. What the Switch Actually Does At its core, the switch acts like a translator and traffic controller. When a prescription is submitted, the switch moves information between the pharmacy, the PBM, and the health plan. It checks eligibility, applies plan rules, calculates pricing, and sends an approval or rejection back to the pharmacy, often in just a few seconds. When this process works well, the member barely notices it. When it does not, the result can be delays, confusing messages, or unexpected out-of-pocket costs. The switch may be invisible, but its impact is felt immediately. Why the Switch Is Often Overlooked Many PBMs do not own or control their switch. Instead, they rely on outside vendors to manage that flow of information. Over time, this creates layers of systems that were not designed to work together. When something goes wrong, it can be difficult to pinpoint the issue. Data may not line up cleanly, fixes can take longer, and the experience becomes fragmented for everyone involved. These challenges rarely show up in a proposal, but they show up quickly at the pharmacy counter. A More Integrated Approach to PBM Technology ProCare Rx takes a more integrated approach by managing its switch alongside its claims processing platform. This matters because the systems are designed to work together from the start, rather than being connected after the fact. With this structure, data flows more cleanly and issues can be identified faster. Rejected claims are easier to understand, pricing logic is clearer, and pharmacies can get answers without unnecessary handoffs. Security is also stronger when fewer external systems are involved. This kind of integration supports simplicity without sacrificing sophistication. The technology may be complex behind the scenes, but the experience is designed to feel straightforward for members and plan sponsors. How the Switch Shapes the Member Experience While members may never hear the word “switch,” they experience its results every time they pick up a prescription. A well-managed switch helps reduce unnecessary claim rejections and supports clearer cost information at the point of sale. It can also help guide members toward better pricing options when discounts or coupons are available. These moments matter, especially when members are already dealing with health concerns. Small improvements in the technology layer often lead to big improvements in trust and satisfaction. Why This Matters Now Pharmacy benefits are not getting simpler. New medications, pricing models, and regulatory pressures continue to add complexity. In this environment, foundational technology becomes critical. PBMs that invest in core infrastructure, like the switch, are better positioned to adapt, respond, and deliver clarity. They are also better equipped to support employers who want transparency and plan members who want fewer surprises. The switch may be one of the most powerful parts of a PBM. And as we launch into 2026, benefits leaders are beginning to look beyond surface-level features and pay closer attention to what is happening behind the scenes.

ProCare Rx Appoints Craig Abrahamson as VP, Consultant Relations

The New Reality of Direct-to-Consumer Drug Marketing

The Next Wave of PBM Reform

Drug costs continue to surge, regulatory winds are shifting, and employers are bracing for steeper expenses ahead. Now more than ever, your choice of PBM partner can be a major differentiator or a liability. Why This Moment Matters Cost growth expectations are steep. Employers are forecasting higher health care costs in 2026, with pharmacy spend as a central contributor. Some projections suggest pharmacy alone may rise by double digits next year, far outpacing general medical cost trends. Reform pressure is building. PBM practices are under increasing scrutiny. Policymakers, physician groups, and pharmacy organizations are pushing for reforms that would delink PBM profits from drug list prices, increase transparency, and ensure savings flow to plan sponsors and patients. PBMs themselves are already floating proposals to adjust their practices ahead of possible legislation. Regulation is becoming inconsistent and complex. While federal courts and Congress weigh in, states continue to pass new PBM laws. For multi-state employers, this means navigating a patchwork of rules that can be confusing, sometimes conflicting, and potentially at odds with fiduciary obligations. What to Look for in a PBM Partner Given this evolving landscape, employers should place extra emphasis on: Regulatory agility and compliance support Your PBM must help you navigate both federal and state-level requirements, protecting your plan against compliance risk. True cost transparency and incentive alignment Demand clarity on how your PBM is compensated. Incentives should be aligned with your plan, not tied to higher drug list prices or opaque rebate arrangements. Formulary integrity and clinical governance With expensive therapies hitting the market, your PBM should balance cost savings with clinical appropriateness, ensuring members receive the right drug, not just the cheapest option. Benefit design flexibility Rising costs require innovative plan designs such as specialty carve-outs, differential cost-sharing, or utilization management. Your PBM should be a partner in shaping these strategies, not a barrier. Member experience and adoption tools With members facing higher cost-sharing and more complex therapies, digital tools, adherence programs, and proactive engagement are essential for better outcomes. Proven performance and benchmarking In this climate, results matter. Your PBM should demonstrate measurable cost savings and clinical outcomes year over year, benchmarked against peers. The Bottom Line  Plan sponsors are entering a pivotal moment. The forces shaping pharmacy benefits include cost escalation, regulatory change, and clinical complexity. The status quo will not be enough. Choosing a PBM partner with regulatory foresight, aligned incentives, clinical integrity, and member-centric tools can help employers navigate this era, mitigate risk, and deliver sustainable value to their workforce. Sources Reuters – Pharma middlemen propose regulatory changes to avoid Trump administration rules Pharmacy Times – Pharmacy policy updates for September 2025 Bloomberg Law – Drug benefit compliance is a state-by-state test for sponsors NASPA – Over 100 pharmacy organizations urge PBM reform AMA – Advocacy update spotlight on PBMs Healthcare Dive – Employers expect 9% higher health costs in 2026 WorldatWork – Business Group on Health predicts 9% higher healthcare costs in 2026 PwC – Behind the numbers: Rising drug spend ProCare Rx PBM 101 video script

The world of pharma is evolving quickly, with direct-to-consumer (DTC) marketing and new patient engagement strategies changing how therapies are launched, prescribed, and accessed. Join John Drakulich for an insightful conversation on The New Pharma Playbook and what these shifts mean for employers, health plans, pharmacies, and patients. Hosted by ProCare Rx , this webinar takes a closer look at how DTC marketing influences prescribing behavior, patient decision-making, and overall drug costs, and how transparent PBM strategies can help plan sponsors navigate these challenges while prioritizing member care. Attendees will walk away with practical insights into how PBMs like ProCare Rx are driving innovation, improving access, and keeping costs under control in a changing marketplace.

PBM 101, Part 1: Why PBMs Matter for Employers