The Department of Labor’s proposed PBM disclosure rule just closed its public comment period — and the pressure to finalize it is intense.
SHN breaks down what’s at stake for your plan.
If you sponsor a self-insured health plan, you’ve probably wondered at some point whether your pharmacy benefit manager is being straight with you.
The answer, for most plan sponsors, is: not entirely.
PBMs occupy one of the most opaque corners of the U.S. healthcare system. They negotiate drug prices, build formularies, process claims, and manage pharmacy networks — all while operating under contract structures so complex that even sophisticated employers struggle to know whether they’re getting a fair deal.
The Department of Labor is trying to change that. Its proposed PBM transparency rule — which just closed its public comment period on April 16, 2026 — would require PBMs to disclose actual dollar figures on rebates, spread pricing profits, and pharmacy clawbacks. Hundreds of stakeholders weighed in. The support was broad, the opposition was predictable, and the implications for plan sponsors are significant.
Here’s what you need to understand.
What the Rule Would Actually Require
Under the proposed rule, PBMs contracting with self-insured group health plans would be required to disclose:
• Rebates received from drug manufacturers — in actual dollar amounts, not just percentages
• Profits from spread pricing arrangements (the difference between what the PBM charges the plan and what it pays the pharmacy)
• Additional payments clawed back from pharmacies on behalf of the employer plan
• Full compensation disclosures both before contract signing and in semiannual reports
• The right to audit those disclosures for accuracy
That last point — audit rights — may be the most important. Transparency without enforcement is just disclosure theater. The ability to verify what you’re told is what gives the rule real teeth.
Why the Push for Transparency Matters
The “Big Three” PBMs — Express Scripts (Cigna), Caremark (CVS), and Optum Rx (UnitedHealth) — collectively control roughly 80% of U.S. prescriptions. That concentration of market power, combined with contract complexity deliberately designed to obscure how money flows, has left plan sponsors essentially flying blind.
Employers know they’re paying for drugs. They don’t always know how much of what they pay flows back to the PBM through rebate retention, spread pricing, or subsidiary GPO arrangements — rather than reducing plan costs. That’s not a hypothetical concern. It’s a structural feature of how major PBMs operate.
This rule would make that structure visible. And visibility tends to change behavior — especially when competitors can see it too.
The Gaps: What the Rule Doesn’t Yet Cover
The rule in its current form has real limitations that commenters — including employer coalitions, Democratic lawmakers, and a bipartisan coalition of 45 state attorneys general — urged the DOL to address.
Fully insured plans are excluded.
The rule currently applies only to self-insured group health plans. Fully insured plans — where PBM services are bundled with the insurance product — would see no new disclosure requirements. Employers in that market would remain in the dark while self-insured counterparts gain meaningful visibility. That’s an inequitable outcome that the DOL should fix before finalizing.
GPO subsidiaries may still hide rebate dollars.
The Big Three PBMs each own Group Purchasing Organization subsidiaries. Those GPOs aggregate buying power across employers and plans to negotiate with drug manufacturers — and then may keep a share of rebates before passing anything to the parent PBM. The proposed rule would require PBMs to disclose rebates they receive, but if GPOs are retaining dollars upstream, the disclosed amounts won’t tell the full story.
Third-party administrators and claims repricers aren’t covered.
Multiple commenters noted that the transparency framework should be extended to other middlemen in the drug supply chain. As a full-service TPA, SHN operates transparently by design — but not every TPA does. Expanding scope would level the playing field and give plan sponsors more complete information.
The PBM Industry’s Response (and Why You Should Be Skeptical)
The Pharmaceutical Care Management Association — the main PBM lobby — called for the rule to be withdrawn entirely. Their arguments: the DOL lacks legal authority, PBMs are already improving transparency voluntarily, and compliance costs would harm smaller PBMs.
These arguments deserve scrutiny. The claim that voluntary transparency is sufficient is hard to square with the fact that plan sponsors have been asking for clear, auditable dollar figures for years — and not getting them. The “harm to small PBMs” argument is a standard lobbying tactic against disclosure rules, applied here to protect an industry where three companies control 80% of the market.
It’s also worth noting that Congress passed the Consolidated Appropriations Act of 2026 in February, which includes its own PBM transparency provisions.
The PBM industry now argues the DOL rule is redundant with the CAA — but as DOL officials have pointed out, the CAA tells PBMs what to do, while this rule gives plan fiduciaries the tools to verify compliance. Those aren’t the same thing.
What This Means for Plan Sponsors Right Now
The rule isn’t finalized yet. But the direction of travel is clear, and smart plan sponsors aren’t waiting for a federal mandate to start asking harder questions of their PBM.
Questions your plan should already be asking:
• Does your PBM contract provide actual dollar amounts for rebates — or just percentages and formulas?
• What spread pricing arrangements exist, and who keeps the spread?
• Does your PBM use a GPO subsidiary? If so, what does it retain before passing through rebates?
• Do you have audit rights, and have you ever exercised them?
• Can your TPA independently verify the information your PBM provides?
If the answers are vague, you’re probably not getting the full picture.
The Bottom Line
Transparency won’t solve every problem in the pharmacy benefit space. But it’s a necessary precondition for fixing anything. Plan sponsors can’t negotiate effectively, switch PBMs intelligently, or hold their administrators accountable without real numbers.
The DOL rule is imperfect and incomplete in its current form. It should cover fully insured plans. It should reach GPO subsidiaries. And it should be finalized quickly, before the window for action closes.
In the meantime, plan sponsors don’t need to wait for Washington. The right TPA and PBM consulting partner can start delivering real transparency today.
How SHN Approaches PBM Consulting
SHN has provided PBM consulting services as part of our full-service TPA offering for decades. We help plan sponsors evaluate PBM contracts, benchmark performance, and understand where their drug dollars actually go — in plain language, with real numbers.
We don’t have a PBM subsidiary. We don’t retain rebates. Our interests are aligned with yours: getting your members the medications they need at a cost your plan can sustain.
If the DOL rule has you thinking about your current PBM arrangements, we’re a good place to start that conversation.