"Transparency" is the "natural" of PBM contracting

“Transparency” is becoming the “natural” of the benefits industry. It sounds reassuring, it sells, and it means whatever the party defining it wants it to mean.

In PBM contracting, transparency has mostly meant rebates. Rebate guarantees, rebate pass-through percentages, rebate audits. A vendor can meet every one of those terms and still keep plenty of margin, because the definition was drawn around the one revenue stream everyone learned to ask about.

Three hospital systems just showed another place to look. Mount Sinai, Michigan Medicine, and the University of Kansas Health System sued CVS Health in May, alleging roughly $250 million in diverted 340B savings. The claimed mechanism: claims adjudicated at standard network rates, then retroactively repriced down weeks later, with the spread retained. None of that would surface in a rebate report.

The 340B funds at issue belong to hospitals, not plans. But the alleged playbook, repricing claims after adjudication where only one party can see the math, runs on capabilities your PBM has too.

Washington has noticed. CAA 2026 now requires 100% pass-through of rebates, fees, and other remuneration to ERISA plans, and the DOL’s proposed 408(b)(2) rule would force disclosure of spread pricing compensation and pharmacy recoupments.

Congress wrote a definition into statute because the contract definitions weren’t doing the job. Most CAA provisions don’t bite until 2029 for calendar year plans, and the fight over what counts as a bona fide service fee is just starting.

Three questions worth asking before your next renewal:

Does your contract fix reimbursement at adjudication, or permit retroactive repricing?

Do your audit rights reach claim-level repricing data, or stop at rebate summaries?

Who performs reconciliation, and does anyone independent ever see it?

The statute arrives in 2029. Your renewal arrives next month.