2025 is proving to be a transformative year for pharmacy benefits management. New federal transparency requirements are shining a spotlight on Pharmacy Benefit Managers (PBMs), forcing these powerful intermediaries to disclose financial practices previously hidden from view. For employers—especially tribal enterprises and mid-sized organizations—this shake-up carries significant implications for plan costs, contract negotiations, and overall pharmacy benefit strategy.

Why the Spotlight on PBMs?

PBMs have long played a pivotal role in determining how much employers pay for prescription drugs. While they negotiate rebates and discounts, PBMs have also faced criticism for:

• Undisclosed rebates and spread pricing tactics.
• Potential conflicts of interest in formulary decisions and pharmacy network design.
• Significant cost variations for identical medications across different PBMs.

In response, the federal government has enacted new rules under the Consolidated Appropriations Act (CAA), clarified by the Department of Health and Human Services (HHS). These regulations now require PBMs to publicly disclose:

• All manufacturer rebates and administrative fees received.
• Actual drug acquisition costs compared to what health plans are billed (known as spread pricing).
• Financial arrangements with pharmacy networks that might influence drug coverage decisions.

While these measures are designed to protect plan sponsors and members from hidden costs, they’re also triggering rapid changes across PBM contracts and pricing strategies in 2025.

What Employers Need to Do Now

Employers cannot afford to stay passive. The PBM marketplace is shifting, and outdated contracts may leave significant savings untapped—or worse, expose employers to hidden costs. Here’s how to stay proactive:

• Request Updated Contracts: PBMs are revising contract terms to comply with new transparency mandates. Employers should demand clear language on rebate handling, reporting obligations, and dispute resolution processes.
• Evaluate Pass-Through Pricing: Many PBMs are shifting toward “pass-through” models where all rebates and discounts flow directly to the employer. Assess whether this structure fits your plan’s size, risk tolerance, and administrative capabilities.
• Demand Detailed Reporting: Require robust reporting that breaks down rebate amounts, drug acquisition costs, and any administrative fees. Transparency without actionable data is of limited value.
• Focus on Specialty Drugs: Specialty medications remain a critical cost driver. The new rules do not automatically lower specialty drug prices, so employers should explore carve-outs, alternative sourcing strategies, or specialty pharmacy partnerships.

For tribal employers and enterprises, these changes are particularly impactful. Many tribal health plans serve geographically remote populations with limited pharmacy access and smaller purchasing leverage, making transparency essential to avoid disproportionately high drug costs.

The Road Ahead

While these federal mandates represent meaningful progress, the PBM landscape remains complex. Some PBMs may seek new revenue streams to offset lost rebate income, potentially shifting costs elsewhere in plan contracts. Employers should anticipate:

• Rapid contract amendments mid-year as PBMs adjust to compliance requirements.
• New administrative fees or service charges replacing prior hidden margins.
• Vendor consolidation or market exits as smaller PBMs struggle with compliance costs.

Proactive plan sponsors should engage experienced advisors, scrutinize every contract revision, and ensure that data-driven analyses back any PBM relationship. The goal is not only compliance—but securing real savings and sustainable pharmacy benefits for employees.

Atria’s Role: Bringing Clarity to Pharmacy Benefits

Atria’s team continually monitors regulatory changes and market trends impacting pharmacy benefits. We support employers by:

• Reviewing PBM contracts for transparency compliance and cost optimization.
• Designing tailored pharmacy strategies aligned with emerging federal requirements.
• Educating plan sponsors on navigating the shifting PBM environment.

Have questions about PBM transparency or how these changes affect your plan? Connect with Atria today to ensure your pharmacy benefits remain compliant, competitive, and financially sustainable.

This article is for informational purposes only and should not be considered legal or tax advice.