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title: Insurance Insights | Benefits
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# DSP Insurance Insights
Get insights on commercial insurance, property and casualty insurance, workplace safety, and employee benefits. Our blog articles deliver expert tips, industry updates, and risk management strategies to help businesses protect their people and profits.
[](https://blog.dspins.com/you-see-one-way-your-pbm-gets-paid.-the-new-rule-shows-you-the-other-five)
## [You See One Way Your PBM Gets Paid. The New Rule Shows You the Other Five.](https://blog.dspins.com/you-see-one-way-your-pbm-gets-paid.-the-new-rule-shows-you-the-other-five)
Nov 5, 2026, 11:30:40 AM / by [Blake Erickson](https://blog.dspins.com/author/blake-erickson) posted in [Benefits](https://blog.dspins.com/topic/benefits)
[0 Comments](https://blog.dspins.com/you-see-one-way-your-pbm-gets-paid.-the-new-rule-shows-you-the-other-five#comments-listing)
Every PBM contract has a line for what the plan pays the PBM. For most employers, that is the only number they ever see. The PBM gets paid at least five other ways, and until now, none of them had to show up on paper.
That is about to change. On October 29, the Department of Labor finalized a rule that makes pharmacy benefit managers disclose, in dollars, every way a self-funded health plan pays them. Level-funded plans count. The first disclosures reach employers in 2027.
Most coverage of the rule walks through what it requires. This article follows the money instead: the six ways a PBM gets paid, which of them you can see today, and where each one shows up once the rule applies to your plan.
## Six Ways a PBM Gets Paid
A PBM sits between your plan, the pharmacies and the drug makers, and money moves in all three directions. (If you want the bigger picture on why pharmacy costs keep climbing, start with [The Prescription Drug Machine](https://blog.dspins.com/the-prescription-drug-machine-what-employers-need-to-know-about-rising-pharmacy-costs).) Here is where the PBM's share comes from.
| 1. Direct fees Administrative fees the plan pays the PBM, per claim or per member. TODAY: In your contract 2027: Split out by service, in dollars | 2. Rebates Payments and fees from drug makers, tied to the drugs your plan covers. TODAY: The share the PBM keeps is hidden 2027: Drug by drug, what comes to the plan and what the PBM keeps |
| --- | --- |
| 3. Spread The PBM charges the plan more for a drug than it pays the pharmacy, and keeps the difference. TODAY: Built into the claim price 2027: The spread on each drug, at retail, mail order and specialty | 4. Clawbacks Money the PBM takes back from pharmacies after a claim is already paid. TODAY: Invisible to the plan 2027: Disclosed in dollars |
| 5. Price protection Payments from drug makers when list prices rise faster than an agreed limit. TODAY: Rarely reported 2027: Disclosed, with who keeps the money | 6. Formulary deals Payments tied to where a drug sits on your formulary, the list of drugs your plan covers. TODAY: Not shown 2027: The PBM names cheaper equivalents it left off, and says why |
| What you see today | | | | | | |
| --- | --- | --- | --- | --- | --- | --- |
| Under the rule | | | | | | |
One of six revenue streams visible today. All six once the rule applies to your plan.
The rule also asks for the net price of every drug on the formulary, after rebates. That is the number that tells you what a drug really costs your plan, and it is the one most employers have never seen.
## Follow One Prescription
Here is how three of those streams can hide inside a single generic prescription. The numbers are round and illustrative, chosen for clean arithmetic.
| The plan pays the PBM $40 for a generic prescription | | |
| --- | --- | --- |
| **$23**Pharmacy keeps | **$15**Spread, kept by the PBM | **$2** |
The PBM pays the pharmacy $25, keeps a $15 spread, and weeks later claws back $2 of the pharmacy's $25. Illustrative figures, not a benchmark.
On a claims report, that is a $40 generic. Nothing else shows. The PBM earned $17 on it, and the plan had no way to know. Under the rule, each of those three numbers gets its own line. Multiply one prescription by every fill in a plan year and you can see why the disclosure matters more than the headline fee.
Brand drugs work differently. There, the money usually moves through rebates and fees from the drug maker. The rule makes the PBM show, drug by drug, how much of that money came to your plan and how much it kept.
## Three Documents, Three Different Jobs
The rule does not hand you one report. It hands you three, each on its own clock.
| **Disclose**Before every renewal or extension | What the PBM expects to make, in dollars. Not a formula, and not a discount off a list price nobody pays. Ninety days before renewal counts as reasonable timing. |
| --- | --- |
| **Report**Every six months, within 30 days | What the PBM actually made. You can ask for quarterly reports. Any category 5% or more over the estimate needs an explanation, and you can negotiate a lower trigger. |
| **Audit**At least once a year | An auditor you choose checks the numbers. The PBM cannot limit who that is. It has 10 business days to confirm the request and 60 days to produce claims-level data and its contracts with pharmacies, drug makers and rebate aggregators, including data its affiliates hold. The plan pays the auditor. The PBM pays to pull the data. |
The report is where the disclosure gets tested. Here is the kind of comparison it makes possible.
| Six-month report (sample) | Estimated | Actual | Over |
| --- | --- | --- | --- |
| Direct fees | $180,000 | $182,400 | 1.3% |
| **Rebates kept by the PBM** | $60,000 | $71,400 | **19.0%** |
| Spread | $45,000 | $46,800 | 4.0% |
| Pharmacy clawbacks | $8,000 | $8,300 | 3.8% |
Illustrative figures and layout. The rule sets what has to be reported, and the 5% trigger. The shaded row crosses it, so the PBM owes an explanation.
A row like the shaded one is the start of a conversation, not the end of one. Maybe a new drug launched and rebates rose with it. Maybe the PBM kept more of them than it promised. The explanation tells you which, and the audit lets you check it.
## Does the Rule Apply to Your Plan?
It depends on two things: how the plan is funded, and how many employees the company has. Employees, not people on the plan. A company with 150 employees and 80 enrolled is in.
| **Self-funded or level-funded** 100 or more employees | **Full disclosure.** Renewal disclosure, six-month reports and the annual audit, for plan years starting on or after July 1, 2027. In a level-funded plan, whoever contracts with the plan for pharmacy, a TPA or the carrier's level-funded product, has to get the PBM's numbers and pass them to you. |
| --- | --- |
| **Self-funded or level-funded** Fewer than 100 employees | **A shorter disclosure.** The 2026 law still requires the PBM to report to you. It is simpler than the detailed version in the rule. |
| **Fully insured** Any size | **Left out, for now.** DOL reserved this part of the rule. And when the law's rebate pass-through starts in 2028, a fully insured plan's rebates go to the insurance company, at least as the law reads today. |
That last row matters for a lot of mid-size employers. If you are fully insured with 100 or more employees, the rule is one more input to the funding conversation. A level-funded plan gets the disclosure. A fully insured plan does not.
## When Does It Reach Your Desk?
Two dates confuse people. The law took effect in February 2026, so part of this is already owed. The detailed rule starts later, on your plan year.
| Feb 3, 2026 | The law is signed. Your PBM, your administrator and your broker owe you a disclosure of what they are paid, starting now. DOL is enforcing it on a good-faith basis while the market catches up. |
| --- | --- |
| Oct 29, 2026 | DOL announces the final rule. |
| Jan 4, 2027 | The rule takes effect. |
| About Apr 2027 | First disclosures for July 1 plans, about 90 days before renewal. |
| Jul 1, 2027 | The rule applies to plan years starting on or after this date. |
| About Oct 2027 | First disclosures for calendar-year plans, whose first plan year under the rule starts January 1, 2028. |
| Aug 3, 2028 | For plan years starting on or after this date, the law requires PBMs to pass 100% of rebates, fees and discounts through to the plan. |
"About" dates assume the disclosure arrives 90 days before renewal, the timing DOL calls reasonable.
Watch the contract term. Many PBM contracts run three years. One signed this year can run straight into the rule, and its own definitions of "rebate" and "spread" will decide what the plan gets until then.
## What the Rule Does Not Do
It does not ban anything. The rule says plainly that it does not prohibit spread pricing. It does not set prices or cap fees. Deciding whether the PBM's pay is reasonable is still the plan fiduciary's job.
Every number in the disclosure also comes from the PBM. That is why the audit right is the most important part of the rule. DOL's own analysis notes the risk that PBMs find new ways to be paid outside what gets disclosed.
Keep the savings in perspective, too. DOL says the rule could lower drug costs by up to $22 billion over 10 years. That is the top of its range. Its primary estimate works out to about $8 billion. The savings go to plans that read the disclosure and act on it.
> A disclosure that sits in a drawer does not protect the plan. It only proves the plan had the information.
## What to Do With the Disclosure
A disclosure is a document. It does not lower a single claim on its own. The value comes from reading it against the contract and acting on what it shows.
- **Ask now.** The law already requires a compensation disclosure from your PBM, your administrator and your broker. Ask each one for it in writing. That includes us.
- **Count back 90 days.** Find your renewal date and put the disclosure date on the calendar. If the contract renews before the rule applies to your plan, write the rule's terms into it now: dollars, drug by drug, quarterly reports, a data file you can analyze, an overage trigger below 5%, and audit rights spelled out.
- **Compare promised with paid.** When the six-month report arrives, line it up against the renewal disclosure. Any category that ran over needs a reason you can accept.
- **Price what the PBM keeps.** Retained rebates, spread and clawbacks are compensation. Put them next to the market for the same services before deciding the deal is reasonable.
- **Write it down.** Record what you reviewed, what you decided and why. That record is what shows the plan was managed in its members' best interest.
- **If the disclosure never comes,** ask the PBM in writing to fix it. If it has not within 90 days, notify DOL within 30 days after that, then decide whether to keep the PBM and document why.
| ## Get a second set of eyes on your first disclosure. DSP's employee benefits team helps self-funded and level-funded employers read PBM disclosures against their contracts, write the rule's terms into renewals, and decide when an audit is worth running. If you are fully insured and wondering whether the rule should change how you fund your plan, that is a conversation worth having before your next renewal. [Talk to Our Benefits Team](https://www.dspins.com/contact/) [Explore Employee Benefits](https://www.dspins.com/employee-benefits/) Or call [847-934-6100](tel:847-934-6100) \| [info@dspins.com](mailto:info@dspins.com) |
| --- |
### Sources
1. Employee Benefits Security Administration, [Improving Transparency Into Pharmacy Benefit Manager Fee Disclosure](https://www.federalregister.gov/documents/2026/11/02/2026-22306/improving-transparency-into-pharmacy-benefit-manager-fee-disclosure), final rule, 91 FR 69092 (November 2, 2026), 29 CFR 2550.408b-22.
2. U.S. Department of Labor, [Fact Sheet: Pharmacy Benefit Manager Fee Disclosure Final Rule](https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/fact-sheets/pharmacy-benefit-manager-fee-disclosure-final-rule) (October 2026). Coverage, timing and good-faith enforcement.
3. U.S. Department of Labor, [news release on the final rule](https://www.dol.gov/newsroom/releases/ebsa/ebsa20261029) (October 29, 2026). Savings estimate.
4. Consolidated Appropriations Act, 2026, sections 6701 and 6702 (signed February 3, 2026). Disclosure duty and the rebate pass-through.
This article is for educational purposes and reflects the final rule and public information as of November 2026. It is not legal, tax, actuarial, or insurance advice. The prescription and report figures are illustrative, chosen for arithmetic clarity, not benchmarks for any specific plan.
[Read More](https://blog.dspins.com/you-see-one-way-your-pbm-gets-paid.-the-new-rule-shows-you-the-other-five)
[](https://blog.dspins.com/chicago-is-down-to-three-hospital-systems)
## [Chicago Is Down to Three Hospital Systems. Your Carrier Can't Say No to Any of Them.](https://blog.dspins.com/chicago-is-down-to-three-hospital-systems)
Oct 15, 2026, 8:59:24 AM / by [Blake Erickson](https://blog.dspins.com/author/blake-erickson) posted in [Benefits](https://blog.dspins.com/topic/benefits)
[0 Comments](https://blog.dspins.com/chicago-is-down-to-three-hospital-systems#comments-listing)
On October 14, Rush University System for Health and Endeavor Health announced plans to merge. Twelve hospitals. More than 400 sites of care. Nearly $11 billion in revenue. The headlines called it the largest health system in Chicago.
That is true if you count hospitals, and only by one. Northwestern Medicine has 11. Advocate has 11 in the region. Take out Endeavor's behavioral health hospital and it is a three-way tie.
So the size is not the story. The story is what is left when the deal closes: three systems that every carrier in Chicago needs in its network, and very little room to say no to any of them.
## How Chicago Got Here
Chicago did not consolidate overnight. It happened one deal at a time, and each one looked reasonable on its own.
NorthShore University HealthSystem absorbed Swedish Covenant in 2020 and Northwest Community in 2021. It merged with Edward-Elmhurst in January 2022 and renamed itself Endeavor at the end of 2023. Now Endeavor joins Rush, and the Endeavor name goes away.
Advocate combined with Aurora in 2018, then with Atrium Health in 2022 to form one of the largest nonprofit systems in the country. Northwestern grew the same way, adding Central DuPage and Delnor in 2014 and more suburban hospitals since.
Here is the part worth remembering. In 2017, the FTC and the State of Illinois went to federal court to stop Advocate and NorthShore from merging. They won, and the two systems walked away. Nine years later, NorthShore's hospitals are headed into a system with more hospitals than anyone else in the region. It just took four deals instead of one (consolidation is patient).
## What This Looks Like From the Negotiating Table
Employers do not negotiate hospital prices. Carriers and networks do, on your behalf, in rooms you are never in.
A carrier's power in those rooms comes from one thing: the ability to walk away. A carrier can leave a mid-size system out of network and still sell a credible product. Leaving out 12 hospitals across the North Shore, the city and the western suburbs is a different conversation. Large systems know that, and they often negotiate all or nothing. Every hospital stays in network at the system's rates, or none of them do.
There is local overlap, too. Rush Copley in Aurora and Edward in Naperville serve neighboring communities. Rush Oak Park and Elmhurst Hospital sit a few suburbs apart. Expect regulators to look hard at those pairs.
> When a market gets down to three must-have systems, the carrier stops negotiating the price and starts negotiating how much of an increase it can live with.
## What the Research Says Happens Next
This is not a guess. Economists have studied hospital mergers for decades, and the pattern holds.
| 6%+ Price increase when merging hospitals sit about 5 miles apart or less Cooper, Craig, Gaynor & Van Reenen, *Quarterly Journal of Economics* (2019) | 7% to 9% Price increase at acquiring hospitals when a system buys a hospital elsewhere in the same state Dafny, Ho & Lee, *RAND Journal of Economics* (2019) |
| --- | --- |
| 12% Higher prices at monopoly hospitals than at hospitals facing four or more rivals Cooper, Craig, Gaynor & Van Reenen (2019) | 30 days Minimum notice Illinois requires to the Attorney General before a health care deal like this closes Illinois Antitrust Act, Section 7.2a |
The second number matters most for Chicago. Dafny's team found that prices rise even when the merging hospitals do not compete for the same patients. The driver is bargaining power with insurers. Distance does not protect you.
## What It Costs a Mid-Market Plan
If you are self-funded, you can run this on your own claims. Here is an illustrative version, with round numbers chosen for clean arithmetic.
| 250-employee self-funded plan | Illustrative |
| --- | --- |
| **Annual medical claims** | $3,000,000 |
| **Claims paid to Rush and Endeavor facilities** | $1,200,000 |
| **Price increase on that spend** | 6% to 9% |
| **Added cost per year** | **$72,000 to $108,000** |
Every year after, compounding with trend. It will not arrive at your next renewal. Carrier contracts with hospital systems typically run multiple years, so new rates show up as those contracts come up. That gap is your window.
Fully insured groups will not see a line item. The increase gets folded into trend and shows up as a renewal number nobody can fully explain. Self-funded groups see it in claims data, hospital by hospital, and they feel it twice: higher unit costs push more large claims past the stop-loss deductible, and specific premiums follow.
## If You Are Self-Funded or a Larger Group
None of this calls for panic. It calls for doing the work before the contracts reprice. These moves assume you can see where your claims go: self-funded plans, and fully insured groups large enough to be rated at least partly on their own experience (in Illinois, typically 51 or more employees), who can often get facility-level reports from the carrier.
- **Measure your exposure.** Pull 24 months of claims by facility. What share of your spend goes to Rush and Endeavor today? If you are fully insured and cannot get that report, that tells you something too.
- **Ask about contract timing.** When does your carrier's or TPA's contract with each system renew? Does it allow tiering or steering?
- **Move shoppable care.** Joint replacements, imaging and infusions rarely need an academic medical center. Centers of excellence and site-of-care programs often beat the local hospital on price and outcomes.
- **Price reference-based pricing for part of the plan.** Paying a set multiple of Medicare caps your exposure to whatever the merged system negotiates. The vendor you pick matters as much as the model.
- **Watch the regulators.** The FTC and Illinois can still challenge the deal or change its terms. Nothing is final until it closes, expected in early 2027.
## If You Are a Smaller, Fully Insured Group
Most of what is above assumes you can see your claims and steer where care happens. Plenty of employers cannot. If you have 50 or fewer employees and buy a fully insured plan in Illinois, here is the honest version.
Your rates are filed with the state and pooled with every other small group your carrier insures. Your own claims history does not move your premium, and there is no hospital contract you get to negotiate. When the merged system reprices, it shows up in everyone's rates at once.
That does not mean you have no moves. They are just different moves.
- **Shop the network, not just the rate.** At renewal, compare plans built on narrower or tiered networks. Some leave out or tier the highest-cost systems, and they are priced accordingly.
- **Use the tools you already pay for.** Federal transparency rules require your carrier to give members an online cost estimator. An MRI at a freestanding imaging center often costs far less than the same scan at a hospital outpatient department. Show your employees where to look.
- **Know whether your group can leave the pool.** This is where your group's health matters. It does not change your small group premium, but it decides whether you qualify for arrangements priced on your own group, like level-funded plans, instead of the whole market.
- **Ask what exists below the radar.** DSP works with alternative arrangements built for groups as small as five enrolled employees (most small employers have never heard of them). They are not right for every group, but they are worth a conversation before your next renewal, not after it.
## The Promise and the Price
Every one of these deals comes with promises: better access, more research, higher quality. Some of that may prove real. Rush and Endeavor have pledged $1 billion tied to the merger, including $500 million for academics and research.
But employers fund those promises through the price of care. Chicago is becoming a three-system market, and three-system markets do not get cheaper on their own. The employers who come out ahead, at any size, will be the ones who know their exposure and have options ready before the next contract cycle, not after it.
| ## Know your exposure before the contracts reprice. DSP's employee benefits team helps Chicago-area employers break down claims by facility, model hospital price exposure, and build steering, center-of-excellence and reference-based pricing options for fully insured, level-funded and self-funded plans, and we bring smaller groups options most brokers never put on the table. If Rush or Endeavor facilities show up in your top claims, or your small group renewal keeps climbing with no explanation, that is the conversation to have. [Talk to Our Benefits Team](https://www.dspins.com/contact/) [Explore Employee Benefits](https://www.dspins.com/employee-benefits/) Or call [847-934-6100](tel:847-934-6100) \| [info@dspins.com](mailto:info@dspins.com) |
| --- |
### Sources
1. CBS Chicago, [Rush University System and Endeavor Health announce merger](https://www.cbsnews.com/chicago/news/rush-university-system-endeavor-health-merger-chicago/) (October 14, 2026). Deal terms, leadership, $1 billion investment, expected early 2027 close.
2. Fierce Healthcare, [Rush University System for Health, Endeavor Health unveil 12-hospital merger](https://www.fiercehealthcare.com/providers/rush-university-system-health-endeavor-health-unveil-12-hospital-merger) (October 2026). 12 hospitals, nearly $11 billion in revenue.
3. Daily Herald, [Endeavor Health and Rush University System for Health announce plans to merge](https://www.dailyherald.com/20261014/health-care/endeavor-health-and-rush-university-system-for-health-announce-plans-to-merge/) (October 14, 2026). Northwestern Medicine and Advocate hospital counts.
4. Federal Trade Commission, [After Two Chicago-area Hospital Systems Abandon Proposed Merger, FTC Dismisses Case](https://www.ftc.gov/news-events/news/press-releases/2017/03/after-two-chicago-area-hospital-systems-abandon-proposed-merger-ftc-dismisses-case-administrative) (March 2017).
5. Zack Cooper, Stuart Craig, Martin Gaynor and John Van Reenen, [The Price Ain't Right? Hospital Prices and Health Spending on the Privately Insured](https://www.nber.org/papers/w21815), *Quarterly Journal of Economics* 134(1), 2019.
6. Leemore Dafny, Kate Ho and Robin Lee, [The Price Effects of Cross-Market Mergers: Theory and Evidence from the Hospital Industry](https://www.nber.org/papers/w22106), *RAND Journal of Economics*, 2019.
7. Illinois Attorney General, [Notifying the Attorney General of Covered Health Care Transactions](https://illinoisattorneygeneral.gov/Consumer-Protection/Health-Care/Antitrust-Health-Care).
This article is for educational purposes and reflects public information as of October 2026. The Rush and Endeavor merger is pending state and federal regulatory approval, and its terms may change. This is not legal, tax, actuarial, or insurance advice. The claim and price figures in the worked example are illustrative, chosen for arithmetic clarity, not benchmarks or a forecast for any specific plan.
[Read More](https://blog.dspins.com/chicago-is-down-to-three-hospital-systems)
[](https://blog.dspins.com/being-the-leader-she-needed-hard-won-hr-lessons-on-careers-benefits-and-trust)
## [Being the Leader She Needed: Hard-Won HR Lessons on Careers, Benefits, and Trust](https://blog.dspins.com/being-the-leader-she-needed-hard-won-hr-lessons-on-careers-benefits-and-trust)
Sep 30, 2026, 9:15:04 AM / by [Blake Erickson](https://blog.dspins.com/author/blake-erickson) posted in [Benefits](https://blog.dspins.com/topic/benefits)
[0 Comments](https://blog.dspins.com/being-the-leader-she-needed-hard-won-hr-lessons-on-careers-benefits-and-trust#comments-listing)
Amy Smith's LinkedIn banner reads: "Being the leader that she needed when she started her career." On the latest episode of DSP's podcast, Uncovered, host Blake Erickson sat down with Amy, HR Manager at Vittori Health, to find out what that means and what HR professionals, executives, and benefits brokers can learn from a career built without a roadmap.
Amy didn't follow the traditional path into HR. Widowed at 28, she needed a better job quickly and applied for a cash office position at Lowe's. Two months later, she was asked to step into the HR role. She fell in love with the work and has been doing it ever since.
[Read More](https://blog.dspins.com/being-the-leader-she-needed-hard-won-hr-lessons-on-careers-benefits-and-trust)
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## [You See One Way Your PBM Gets Paid. The New Rule Shows You the Other Five.](https://blog.dspins.com/you-see-one-way-your-pbm-gets-paid.-the-new-rule-shows-you-the-other-five)
#### [You See One Way Your PBM Gets Paid. The New Rule Shows You the Other Five.](https://blog.dspins.com/you-see-one-way-your-pbm-gets-paid.-the-new-rule-shows-you-the-other-five)
Every PBM contract has a line for what the plan pays the PBM. For most employers, that is the only number they ever see. The PBM gets paid at least five other ways, and until now, none of them had to show up on paper. That is about to change. On October 29, the Department of Labor finalized a rule…
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#### [Chicago Is Down to Three Hospital Systems. Your Carrier Can't Say No to Any of Them.](https://blog.dspins.com/chicago-is-down-to-three-hospital-systems)
On October 14, Rush University System for Health and Endeavor Health announced plans to merge. Twelve hospitals. More than 400 sites of care. Nearly…
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#### [Being the Leader She Needed: Hard-Won HR Lessons on Careers, Benefits, and Trust](https://blog.dspins.com/being-the-leader-she-needed-hard-won-hr-lessons-on-careers-benefits-and-trust)
Amy Smith's LinkedIn banner reads: "Being the leader that she needed when she started her career." On the latest episode of DSP's podcast, Uncovered,…
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