A more tailored PBM audit scope As an independent consulting firm, Ethica listens to its clients to understand their needs and assesses audits around what is heard versus what is standard and off the shelf. That means the audit scope is built around what matters most to the client, not a one-size-fits-all framework. This approach helps ensure the findings are relevant, practical, and aligned with the client’s priorities. “At Ethica,…

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When managing a PBM audit or procurement, turning to an independent agency ensures objective feedback and reduces risk. At Ethica Pharmacy Advisors, we bring more than independent, in-house expertise—we go beyond the spreadsheets, minimizing human error with our custom-built automation tools. Hear from Ethica’s Pharmacy Intelligence Consultant, Morgan Clark, on Ethica’s auditing approach and the optimized processes behind delivering accurate, efficient, and transparent insights for our clients. Ethica’s PBM audit…

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On April 6, 2026, the Centers for Medicare & Medicaid Services (CMS) released final rules regarding Medicare Part D creditable coverage disclosures and determinations. Specifically, CMS eliminated the requirement for account-based plans, including Individual Coverage Health Reimbursement Arrangements (ICHRAs), to provide creditable coverage disclosures and finalized changes to the simplified method for determining a plan’s creditable coverage status. As a reminder, CMS requires employers, as group health plan sponsors, to…

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On February 4, 2026, the Federal Trade Commission accepted a consent agreement for public comment regarding a settlement with Express Scripts, Inc. and its affiliated entities (collectively “ESI”). Once the consent order is issued by the Commission, it carries the force of law. The settlement resolves the lawsuit filed by the Commission against ESI regarding alleged inflation of insulin drugs through their rebating practices, shifting the cost to patients. Settlements…

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While PBM arrangements remain complex, the real question for organizations heading into 2026 is clear: How do you ensure your contracts are performing as promised? Hear from Ethica Pharmacy Advisors as we break down what a pharmacy benefits audit really is and why it’s one of the most powerful tools employers need to take control of their pharmacy spend without compromising care. “We find a comprehensive audit helps our clients…

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Ethica State Law Alert On July 1, 2025, Illinois House Bill 1697, also known as the Prescription Drug Affordability Act, was signed into law. Key provisions of this Act applicable to employer sponsored group health plans and Pharmacy Benefit Manager (PBM) contracts, including PBM audit and transparency requests, are effective as of January 1, 2026. These key provisions for employers offering prescription drug coverage in Illinois are outlined below: Next…

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Recent headlines are drawing attention to the opacity of pharmacy benefit managers (PBMs), as policymakers, employers, and the media increasingly question how drug prices are set and who truly benefits.

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On May 15, 2025, the Departments of Labor, Health and Human Services and the Treasury announced they will not enforce the September 2024 regulations implementing the NQTL comparative analysis requirement under the Mental Health Parity and Addiction Equity Act as required by the Consolidated Appropriations Act, 2021.

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