Are Employers Getting Access to PBM Claims Data?

Q: Are employers having any success including language in NEW contracts that requires access to claims data?

Jamie Greenleaf, co-founder, Fiduciary in a Box; Julie Selesnick, director, legal and compliance, Judi Group and founder and principal attorney, Health Plan Legal Counsel; and Rory Akers, vice president, senior ERISA compliance attorney, Lockton Companies, answer below:

A: Absolutely—employers offering self-funded health plans of all sizes are successfully negotiating meaningful claims-data access in new service agreements with third-party administrators (TPAs) and pharmacy benefit managers (PBMs), an important step in fulfilling their duty to act as prudent fiduciaries.

The most effective time to secure strong data access rights is when negotiating a new contract, more specifically during a request for proposal (RFP) or similar competitive process. When multiple TPAs or PBMs are competing for your business, the balance of power shifts. Even incumbents who previously claimed their “hands were tied” often become far more flexible once they know another vendor could win the contract. Competition matters—and it works.

To get the best results, data access should be addressed early and explicitly. Your RFP (or other competitive request for TPA or PBM services) should clearly state that access to claims data is non-negotiable and require bidders to include contract language that gives the plan sponsor and its chosen business associates ongoing electronic access to complete claims data, consistent with section 201 of the Consolidated Appropriations Act of 2021 and the plan’s fiduciary responsibilities. In practical terms, this means usable data, containing all fields the plan (with help from its data vendor) deems necessary, delivered regularly, without unnecessary delays, fees, or approvals.

Even better, many employers are now taking the proactive step of providing their own contract language as part of the RFP. TPAs/PBMs are then required either to accept that language as written or to clearly mark up any changes they propose. This approach does two important things: it prevents vague promises that fall apart later, and it makes it easy to compare vendors side by side on what they are actually willing to commit to in writing.

It is important to note that there is still some hesitation from service providers to make available certain types of data, which is why it is key to have broad language that clearly provides access to all plan data. One key issue to watch for is restrictions that quietly undermine access, also known as “gag clauses.” These can show up as limits on how or when data can be used, shared, or analyzed. Strong contracts make clear that the plan controls the claims data, has the right to share the data with the business associates of its choosing, and the right to use it as necessary for payment and healthcare operations, including proper plan administration, cost management, vendor vetting and monitoring, and to make better fiduciary decisions.

Bottom line: employers that treat claims data as a core business asset—and insist on contract language to match—are succeeding. With the right timing, clear expectations, and a competitive process, meaningful data access is achievable for self-funded plans of all sizes.

NEWS UPDATE: PBM Disclosure Changes

The Consolidated Appropriations Act of 2026, signed into law on February 3, included a set of PBM accountability measures. It creates a mandatory reporting regime requiring PBMs to deliver reports to group health plans at least semi-annually, with quarterly reporting available on request. Reports must be provided in both plain language and machine-readable formats. The reports are required to disclose prices, rebates, fees, alternative discounts, spread pricing arrangements and information on why higher-cost drugs receive preferential formulary placement over cheaper alternatives. The law, which includes steep penalties for noncompliance, is slated to take effect in 2028.

Also this month, the Department of Labor proposed a rule that would require heightened 408(b)(2)(B) compensation disclosures from pharmacy benefit managers including compensation from rebates, spread pricing, clawbacks, and more. Comments on the proposal are due by March 31. If you want to know more about the new law or proposed rule, here are some additional resources:

PBM Disclosure Push Intensifies as Congress Acts

Attorneys Discuss Implications as PBMs Face Rebate Pass-Through Mandate, Fee-Disclosure Rules
DOL Proposal Targets PBM Disclosure Information

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NOTE: This feature is to provide general information only, does not constitute legal advice and cannot be used or substituted for legal or tax advice.

Do YOU have a question about health benefit fiduciary duties? If so, we would love to hear from you! Simply forward your question to Amy.Resnick@issmarketintelligence.com with Subject: Health Plan Fiduciary How-To, and the experts will do their best to answer your question in a future column.