Improving Transparency into Pharmacy Benefit Manager Fee Disclosure

A rule to improve transparency of PBM compensation

Top 5 FAQs about Pharmacy Benefit Manager Fee Disclosure

1. Who does this rule apply to?

   The rule applies to PBMs and their affiliated brokers and consultants (covered service providers) that contract with large self-insured group health plans to provide pharmacy benefit management services. It also affects the health plan sponsors and fiduciaries who would receive and rely on the disclosures.

2. What are PBMs and their affiliates required to disclose?

   Covered service providers need to disclose direct compensation received from the group health plan, as well as compensation reasonably expected from other sources, including:

   • Payments from drug manufacturers

   • Spread compensation (the difference between what the plan pays and what the pharmacy is reimbursed)

   • Claw-backs (payments recouped from pharmacies)

   • Price protection arrangements

3. When do these disclosures need to be made?

   PBMs and their affiliates need to give plan fiduciaries an initial disclosure before entering into, renewing, or extending a contract. Afterward, they need to provide semiannual (or quarterly, if requested by the plan) disclosures showing the compensation actually received, so fiduciaries can continue monitoring the arrangement over time.

4. How can plan fiduciaries verify that the disclosures are accurate?

   The rule allows plan fiduciaries to audit the compensation information that PBMs and their affiliates disclose at least once a year. The fiduciary selects the auditor, and the plan compensates the auditor.

5. What happens if a PBM doesn't comply with the disclosure requirements?

   If a covered service provider doesn’t meet the rule's requirements, fiduciaries can get relief from an administrative exemption if they take specific steps in response to non-compliance, including notifying the Department if the PBM doesn't correct the failure. Fiduciaries can report non-compliance using the Department’s online portal.

Tools and Resources

Final Rule Fact Sheet

DOL released a rule to improve transparency into fees and compensation received by pharmacy benefit managers (PBMs) and their affiliates, including affiliated providers of brokerage and consulting services.

Learn more about PBM fee disclosure final rule

Proposed Rule Fact Sheet

This fact sheet explains the pharmacy benefit manager fee disclosure rule in its proposed form, before it was finalized.

Learn more about the PBM fee disclosure

Law and Regulations

News and Updates