NHC Comments on Improving Transparency Into Pharmacy Benefit Manager Fee Disclosure

NHC Comments on Improving Transparency Into Pharmacy Benefit Manager Fee Disclosure

April 15, 2026

U.S. Department of Labor
Employee Benefits Security Administration
Office of Regulations and Interpretations
200 Constitution Avenue NW
Washington, DC 20210

RE: Improving Transparency Into Pharmacy Benefit Manager Fee Disclosure [RIN 1210-AB37]

Submitted via regulations.gov

The National Health Council (NHC) appreciates the opportunity to comment on the Department of Labor's proposed rule regarding pharmacy benefit manager (PBM) fee disclosure requirements.

Created by and for patient organizations more than 100 years ago, the NHC brings diverse organizations together to forge consensus and drive patient-centered health policy. We promote increased access to affordable, high-value, sustainable health care. Our membership includes more than 180 national health-related organizations, including leading patient organizations representing individuals with chronic disease, disability, and rare conditions, as well as provider associations, caregivers, researchers, and health-related businesses.

While the NHC recognizes the Department's efforts to enhance transparency in arrangements between group health plans and their service providers, we emphasize that transparency alone does not guarantee improved patient outcomes. As patients and caregivers navigate increasingly complex coverage environments, the value of these proposed disclosures will ultimately depend on whether they can provide meaningful, actionable information that plan fiduciaries can effectively interpret to support access to clinically appropriate and affordable therapies.

Ensuring Disclosures are Meaningful and Actionable

The NHC supports the Department's focus on providing plan fiduciaries with greater visibility into direct and indirect PBM compensation arrangements. For these disclosures to be effective, they must be structured in a clear, consistent format that allows fiduciaries to understand compensation sources and assess how such structures may interact with formulary design, utilization management, and patient cost-sharing obligations.1,2,3,4 Furthermore, these disclosures should support meaningful comparisons across service providers, enabling fiduciaries to determine whether compensation is reasonable relative to the services provided.5,6 To improve the usability of this data-particularly for plan sponsors lacking specialized expertise in pharmacy benefit design-the NHC encourages the Department to consider providing additional standardization or explanatory context within the disclosure framework.

Connecting Transparency to Patient Experience

From a patient perspective, the relevance of PBM compensation structures lies in their potential to influence out-of-pocket costs at the point of sale, access to prescribed therapies, and long-term continuity of care.7,8,9,10,11 While the proposed rule appropriately focuses on fiduciary obligations under ERISA, we encourage the Department to recognize the downstream implications these arrangements have for patients and caregivers.12,13 To the extent feasible within statutory authority, the NHC encourages the Department to clarify how disclosed information can assist fiduciaries in evaluating whether benefit designs are operating in a manner that proactively supports access to medically appropriate care.

Promoting Clarity Without Imposing Unnecessary Burden

The NHC appreciates the Department's effort to balance enhanced transparency with administrative feasibility. Requirements that are complex or difficult to operationalize can limit the practical utility of disclosures.14,15,16 The NHC therefore encourages the Department to align these requirements with existing reporting frameworks where possible to minimize duplication. Additionally, providing clear definitions, illustrative examples, and technical guidance-potentially through a phased approach-would reduce variability in interpretation and support more consistent, effective implementation.17,18,19,20

Supporting Ongoing Evaluation

Given the evolving nature of pharmacy benefit design, the NHC encourages the Department to monitor implementation of these proposed requirements and assess their effectiveness over time. It would be highly valuable to evaluate whether plan fiduciaries are successfully utilizing this information in their contracting and oversight decisions, and whether this increased transparency translates into improved clarity regarding the relationship between plan design and patient affordability. Such evaluation is essential to inform future refinements to the framework.21,22

Conclusion

The NHC appreciates the Department's attention to transparency in pharmacy benefit arrangements and its potential to support more informed decision-making by plan fiduciaries. As the Department finalizes this rule, the NHC encourages a continued focus on ensuring that disclosures are meaningful, actionable, and capable of supporting improved patient access and affordability over time.

Thank you for the opportunity to provide comments on this proposed rule. Please do not hesitate to contact Kimberly Beer, Senior Vice President, Policy & External Affairs at [email protected] or Shion Chang, Assistant Vice President, Policy & Regulatory Affairs at [email protected], if you or your staff would like to discuss these comments in greater detail. The NHC looks forward to continued engagement on this issue.

Sincerely,

Randall L. Rutta
Chief Executive Officer

1 Karen Mulligan and Darius Lakdawalla, Hidden Profits? How Accounting Conventions and Vertical Consolidation Can Obscure PBM Profitability (Los Angeles, CA: USC Schaeffer Center, January 22, 2026), https://schaeffer.usc.edu/research/pbm-profitability/.

2 U.S. Government Accountability Office, Medicare Part D: Use of Pharmacy Benefit Managers and Efforts to Manage Drug Expenditures and Benefit Design, GAO-19-498 (Washington, DC: GAO, 2019), 22, https://www.gao.gov/products/gao-19-498.

3 AHIP, "PBMs: Impact on Employer-Provided Coverage Transparency," AHIP Resources, 2024, https://www.ahip.org/resources/pbms-impact-on-employer-provided-coverage-transparency.

4 The Pew Charitable Trusts, The Prescription Drug Landscape, Explored (Washington, DC: Pew Charitable Trusts, 2019), 15, https://www.pewtrusts.org/en/research-and-analysis/reports/2019/03/08/the-prescription-drug-landscape-explored.

5 U.S. Government Accountability Office, Medicare Part D: CMS Should Monitor Effects of Rebates on Plan Formularies and Beneficiary Spending, GAO-23-105270 (Washington, DC: GAO, 2023), https://www.gao.gov/products/gao-23-105270.

6 GAO, Medicare Part D: CMS Should Monitor Effects of Rebates.

7 Neeraj Sood et al., The Flow of Money Through the Pharmaceutical Distribution System (Los Angeles, CA: USC Schaeffer Center, 2017), https://schaeffer.usc.edu/research/flow-of-money-through-the-pharmaceutical-distribution-system.

8 Gary Claxton et al., "Increases in Cost-Sharing Payments Continue to Outpace Wage Growth," Peterson-Kaiser Health System Tracker, June 24, 2018, https://www.healthsystemtracker.org/brief/increases-in-cost-sharing-payments-have-far-outpaced-wage-growth/.

9 Sherry Glied and Sarah R. Collins, Reducing Wasteful Spending in Employers' Pharmacy Benefit Plans (New York, NY: Commonwealth Fund, 2019), https://www.commonwealthfund.org/publications/issue-briefs/2019/aug/reducing-wasteful-spending-employers-pharmacy-benefit-plans.

10 Nancy Haff et al., "Association Between Cost-Saving Prescription Policy Changes and Adherence to Chronic Disease Medications: An Observational Study," Journal of General Internal Medicine 37, no. 3 (2022): 531-38, https://doi.org/10.1007/s11606-021-07031-w

11 Pragya Kakani et al., "Use of and Steering to Pharmacies Owned by Insurers and Pharmacy Benefit Managers in Medicare Part D," JAMA Health Forum 6, no. 1 (2025): e244874, https://doi.org/10.1001/jamahealthforum.2024.4874.

12 AHIP, "PBMs: Impact on Employer-Provided Coverage."

13 T. Joseph Mattingly II, David A. Hyman, and Ge Bai, "Pharmacy Benefit Managers: History, Business Practices, Economics, and Policy," JAMA Health Forum 4, no. 11 (2023): e233804, https://doi.org/10.1001/jamahealthforum.2023.3804.

14 Mark Fiedler, Loren Adler, and Richard G. Frank, "A Brief Look at Current Debates About Pharmacy Benefit Managers," Brookings Institution, 2023, https://www.brookings.edu/articles/a-brief-look-at-current-debates-about-pharmacy-benefit-managers/.

15 David N. Bernstein and Jonathan R. Crowe, "Price Transparency in United States' Health Care: A Narrative Policy Review of the Current State and Way Forward," Inquiry 61 (2024): 1-11, https://doi.org/10.1177/00469580241255823.

16 Matthew Fiedler and Yihan Shi, "Comments on the Transparency in Coverage Proposed Rule," Brookings Institution, February 25, 2026, https://www.brookings.edu/articles/comments-on-the-transparency-in-coverage-proposed-rule/.

17 Medicare Payment Advisory Commission (MedPAC), Report to the Congress: Medicare Payment Policy (Washington, DC: MedPAC, March 2024), https://www.medpac.gov/document/march-2024-report-to-the-congress-medicare-payment-policy/.

18 Agency for Healthcare Research and Quality, Registries for Evaluating Patient Outcomes: A User's Guide, 4th ed. (Rockville, MD: AHRQ, 2020), https://effectivehealthcare.ahrq.gov/products/registries-guide-4th-edition.

19 Blue Cross Blue Shield Association, A Roadmap to Affordability (Washington, DC: BCBSA, 2026), https://www.bcbs.com/news-and-insights/report/rising-health-costs-solutions.

20 U.S. Government Accountability Office, Standards for Internal Control in the Federal Government (Washington, DC: GAO, 2014), https://www.gao.gov/products/gao-14-704g.

21 U.S. Government Accountability Office, Federal Information Transparency: Action Needed to Improve Efficiency and Effectiveness and Enhance Program Integrity, GAO-26-109034 (Washington, DC: GAO, March 2026), https://www.gao.gov/products/gao-26-109034.

22 U.S. Government Accountability Office, Designing Evaluations: 2012 Revision, GAO-12-208G
(Washington, DC: GAO, 2012), https://www.gao.gov/products/gao-12-208g.