Insights

The traditional PBM is being more actively examined as concerns around transparency, affordability and market concentration continue to grow.

Manufacturer copay assistance programs are designed to lower out-of-pocket costs for patients on expensive brand medications, but their impact depends on how they interact with your plan design.

Orforglipron (Foundayo) is the first nonpeptide, oral, once‑daily GLP‑1 receptor agonist, marking a meaningful shift in GLP‑1 therapy.

With increased attention on healthcare regulations, RxDC reporting requirements have exposed data gaps and accountability challenges in pharmacy data flows between employers, PBMs and third-party administrators.  

On April 7, 2026, in McKee Foods Corporation v. BFP, Inc. dba Thrifty Med Plus Pharmacy, the Sixth Circuit U.S. Court of Appeals (Sixth Circuit) held that Tennessee’s “any willing pharmacy” laws are preempted by ERISA. Background McKee Foods, a Tennessee bakery, sponsors a self-insured, ERISA-governed health plan with a prescription drug program (PDP) that favors in-network pharmacies. Thrifty Med, which was formerly in-network, was removed in 2019 and spent the next three years seeki

The DOL, Treasury, and HHS (the departments) recently released the 2025 MHPAEA Report to Congress (the 2025 Report), summarizing enforcement efforts and key findings on the CAA 2021 nonquantitative treatment limitation (NQTL) comparative analysis requirement. Background The CAA 2021 amendments to MHPAEA require plans and insurers to prepare and document a comparative analysis of the design and application of NQTLs (e.g., prior authorization requirements and treatment exclusions). The analysis m

On May 4, 2026, the IRS issued Revenue Procedure 2026-22, which provides the 2027 ACA employer mandate penalty amounts. The penalty amounts increased compared to 2026. The ACA employer mandate requires applicable large employers (ALEs), those with 50 or more full-time employees and full-time equivalent employees, to offer affordable minimum value (MV) coverage to all full-time employees and their dependents or risk a penalty. As outlined below, an employer can be assessed one of two potential p

As a reminder, by July 1, 2026, insurers and employer plan sponsors must comply with applicable reporting and payment obligations under the state’s Vaccine Purchasing Act (VPA). The VPA was enacted in 2015 and imposes surcharges on health insurers and group health plans to fund state projects, including the purchase of vaccines for children in the state. The reporting helps the state assess the quantity of vaccines to purchase, store, and distribute to insured children in th

On April 22, 2026, the state of Virginia enacted a new Paid Family and Medical Leave (PFML) insurance program, which will be administered by the Virginia Employment Commission (VEC). The new program will apply to all private and public sector employers in Virginia, with payroll contributions beginning April 1, 2028, and benefits beginning December 1, 2028. Employers with at least 11 employees must remit both employer and employee payroll contributions, while employers with 10 or fewer employees