By Jake Velie, Chairman & CEO, National Integrative Health

 

The most important sentence in some PBM paperwork is not buried in the pricing exhibit. It is not in the rebate schedule. It is not in the reporting package.

It is the disclaimer.

In one PBM pharmacy service agreement reviewed by our team, the language is direct: in providing services under the agreement, the PBM “is not acting as a fiduciary” under ERISA, and the client “shall not name” the PBM “as a plan fiduciary.”¹ That is not unusual. It is honest contract drafting. But it should get every self-funded employer’s attention.

Why? Because the plan sponsor still holds the liability, even while the PBM controls a huge amount of the machinery.

PBMs adjudicate claims. They build networks. They negotiate rebates. They issue reports. They manage specialty channels. They influence formularies and utilization patterns. But when it comes to fiduciary responsibility, many of them are telling employers exactly where they stand: not here.

What one PBM does well

To be clear, this is not a hit piece on any single company. The agreement and reporting package we reviewed show a PBM doing a number of operational things employers need done. 

The contract lays out claims processing, network administration, customer service, implementation support, audits, reporting, specialty pharmacy services, and rebate administration.² The fee schedule is straightforward enough to tell the client what it will pay for paid claims, prior authorizations, reporting requests, and other administrative functions.³ The agreement also states that the manufacturer’s rebate share to the client is 100%.³

The reporting itself is also the kind of visibility many employers say they want. The 2025 and Q1 2026 client summary reports show plan spend, member spend, rebates, net plan spend, generic utilization, specialty concentration, and other utilization markers.⁴ That is useful information. Employers need reporting. They need operational execution. They need a PBM that can keep the benefit running.

But here is the mistake too many plan sponsors still make: they confuse administration with alignment.

A clean report is not a fiduciary strategy. A rebate line is not a fiduciary strategy. A contract that spells out responsibilities is not the same as a partner taking fiduciary responsibility off your plate.

It does not.

The sentence employers cannot ignore

ERISA does not let a plan sponsor shrug and point downstream. The fiduciary standard follows the employer’s role in managing plan assets and plan decisions.⁵ If your PBM agreement says the PBM is not the fiduciary, believe it. 

That means the employer still owns the hard questions:

1. Are we paying the lowest net cost available for this drug?
2. Are rebate economics distorting our decision-making?
3. Are we overusing high-cost sites of administration?
4. Are there lower-cost biosimilar or therapeutic alternatives?
5. Are we using Manufacturer Assistance Programs (MAP), foundation support, and patient assistance opportunities where appropriate?
6. Do we have a documented process showing we evaluated those alternatives?
   

That last point matters more every year. The Consolidated Appropriations Act forced more disclosure into the pharmacy benefit system, but disclosure alone does not satisfy fiduciary duty.⁶ Transparency tells you where the problem is. You still need a solution.

Reporting does not equal optimization

The summary reports make the point for me.

In the 2025 report reviewed by NIH, specialty plan spend accounted for 71.6% of total plan spend.⁴ In Q1 2026, that figure rose to 88.1%.⁴ Those are not abstract numbers. That is concentration risk. That is exactly why employers cannot afford to look at pharmacy through a single-channel PBM lens.

Even with rebates reflected in the reporting, the employer still needs an independent strategy for where each claim should go and which levers should be pulled. If specialty utilization is dominating spend, the employer cannot be satisfied with getting a quarterly report and hoping the economics work themselves out.

At NIH, we take the opposite view. We assume every high-cost claim deserves to be challenged.

Where NIH changes the equation

National Integrative Health is not trying to become the PBM. We are the managed services layer that sits on the employer’s side of the table.

It is also important to be clear about what we are not. NIH is not the plan fiduciary. The employer still holds that responsibility. Our role is to help plan sponsors meet it with better oversight, better documentation, and better net-cost execution.

That matters because our job is not to protect a single channel. Our job is to drive the lowest net cost across all available channels.

That means looking at 340B pricing, biosimilar pathways, site of administration optimization, Manufacturer Assistance Programs (MAP), clinical interventions, foundation and patient assistance advocacy, and clinical trial access.⁷ ⁸ We are not dependent on a single regulatory outcome or a single vendor revenue model. We are focused on the employer’s result. 

So, when a PBM contract says, in effect, “we administer the program but we are not the fiduciary,” our response is simple: then the employer needs someone on its side who is actually waking up every day thinking like an owner. 

That is where NIH fits. 

This is a partner model, not a replacement fantasy 

Employers do not need to blow up their ecosystem to fix this problem. 

Brokers still matter. TPAs still matter. PBMs still matter. Auditors and consultants still matter. 

But each of those partners has a different role. 

Brokers connect plan sponsors to expertise. TPAs handle claims administration. PBMs process the pharmacy benefit and related operations. Auditors test the math and the compliance record. NIH helps the employer prove it asked the right questions, evaluated the right alternatives, and pursued the lowest net cost available.

That is the gap I see again and again in this market. Plenty of reporting. Plenty of vendors. Plenty of activity. Not enough employer-side orchestration.

Do not wait for the contract to save you 

If your PBM has already told you in writing that it is not the fiduciary, take that statement seriously. 

Do not wait for another lawsuit, another regulatory bulletin, or another renewal cycle to start building your fiduciary record. Start now. Review the contract language. Review the reporting. Review where specialty dollars are going. Then put a managed services strategy in place that proves you pursued the lowest net cost, not just the most convenient status quo. 

The employers who get ahead of this will not be the ones with the prettiest PBM dashboard. They will be the ones who can show they understood the risk, challenged the model, and acted. 

That is the standard now. And it should be. 

 

Jake Velie is Chairman & CEO of National Integrative Health, a managed services organization headquartered in West Des Moines, Iowa, specializing in prescription drug cost optimization for employer health plans.

 

Footnotes

1. PBM pharmacy service agreement reviewed by NIH, effective April 1, 2017, Article VI, Section 6.2. Source material on file.
2. PBM pharmacy service agreement reviewed by NIH, effective April 1, 2017, Exhibit A, Scope of Services. Source material on file.
3. PBM pharmacy service agreement reviewed by NIH, effective April 1, 2017, Exhibit B, Administrative Fee Schedule, including claims processing fee and manufacturer rebate share to client. Source material on file.
4. 2025 and Q1 2026 client summary reports reviewed by NIH. Source material on file.
5. Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1002(21)(A), defining fiduciary functions under ERISA.
6. Consolidated Appropriations Act, 2021, Pub. L. No. 116-260, Division BB, Title II, establishing prescription drug cost reporting and related transparency obligations for group health plans and issuers.
7. National Integrative Health, “About Us,” describing NIH’s managed services model for prescription drug cost optimization. https://nationalintegrativehealth.com/
8. Magellan Rx Management, “Medical Pharmacy Trend Report: Site of Care Optimization,” describing savings potential from shifting infusion administration to lower-cost settings.

By Jake Velie, Chairman & CEO, National Integrative Health

The momentum toward pharmacy benefit manager transparency just got a significant boost. As reported by Allison Bell in BenefitsPro on July 17, 2026, DOL Secretary nominee Keith Sonderling told the Senate Health, Education, Labor and Pensions (HELP) Committee that drafting new PBM transparency regulations is a priority for the Department of Labor.¹ The full hearing is available on the Senate HELP Committee’s website for anyone who wants to hear it straight from the source.²

“That’s going to save billions and billions of dollars for health care plans, which is going to drive down the cost of health care plans,” Sonderling stated during the hearing. He added that employers have “never been armed with information about what they’re paying for” and that “for the first time, they’re going to have that information.”¹

This is exactly the fight we’ve been in for years at National Integrative Health.

Why This Matters to Employers Right Now

For too long, PBMs have operated behind a curtain of complexity, profiting from spread pricing, rebate retention, and opaque formulary steering that costs plan sponsors billions annually. Sonderling’s commitment to transparency validates what we at NIH have built our entire model around: giving employers real visibility and real options to reduce their prescription drug spend.

This isn’t a new fight at the federal level. The Consolidated Appropriations Act of 2021 first cracked open the door by requiring group health plans to report prescription drug cost data and mandating PBM disclosure of rebates and fees.³ The DOL’s Transparency in Coverage Final Rule further required machine-readable pricing files from plans.⁴ And earlier this year, new federal PBM transparency laws created a collision with the DOL’s draft regulations that were already in motion, slowing the rulemaking process.⁵

Sonderling, who was confirmed as deputy secretary of Labor in March 2025 and became acting secretary after Lori Chavez-DeRemer resigned in April 2026,⁶ has now made it clear these regulations are back on the front burner. His oversight of the Employee Benefits Security Administration (EBSA), the agency that writes and enforces ERISA health plan rules, gives him direct authority to make this happen.⁷

At National Integrative Health, we don’t rely on a single strategy or hope that regulation will eventually fix the system. We deploy a multi-lever approach to achieve the lowest net cost on every claim, for every member:⁸

1. 340B Pricing: Access to the lowest U.S. source pricing available across all 50 states
2. Biosimilars: Therapeutic equivalents delivering 60–80% savings over brand medications
3. 503B Manufacturer Direct Contracting: Direct relationships with 503B outsourcing facilities for compounded specialty medications at a fraction of brand pricing
4. Proprietary 50-State Infusion Network: Our nationwide site of administration network redirects infusion and injection therapies from high-cost hospital outpatient settings to lower-cost, clinically equivalent alternative sites of care, saving plans 40–60% per administration⁹
5. Variable Copay Programs: Direct-to-manufacturer programs for GLP-1s and specialty medications
6. Clinical Interventions: Therapeutic substitutions, patient assistance programs, and provider coordination
7. Clinical Trial Program Access: Connecting eligible members to manufacturer-sponsored clinical trials, providing access to cutting-edge therapies to patients and large savings to plans in qualifying circumstances

This multi-channel model means we’re never dependent on any single regulatory outcome. If one lever faces headwinds, we pivot to the next-best option for the plan and the patient.⁸

Transparency Is Necessary, But Not Sufficient

While I applaud the DOL’s direction, employers shouldn’t wait for regulations to take action. Bell’s reporting notes that new draft or final regulations “may not come out in the next few weeks,” and that the department’s efforts have been slowed by the intersection of new congressional PBM transparency laws and existing draft regulations.¹ ⁵ When Sen. Bill Cassidy asked about a timeline, the best Sonderling could offer was, “We are working very hard on it.”¹

The reality is this: transparency tells you where the problem is. You still need a solution. That’s where a managed services organization like NIH comes in. We sit on the same side of the table as the employer, armed with clinical expertise and pricing intelligence across multiple channels, to ensure every dollar spent on pharmacy benefits is optimized.⁸

The Bigger Picture

As Sonderling moves through his confirmation process, his oversight would extend to ERISA-governed health plans, ACA employer provisions, and any new PBM legislation.¹ ⁷ These are the very regulatory frameworks that shape how employers structure and manage their health benefits. Having a Labor Secretary who views PBM accountability as a core priority signals a meaningful shift.

Sonderling also expressed enthusiasm at the hearing for creating benefit solutions for gig workers, programs that could let multiple platforms contribute to a worker’s benefit account without triggering employee classification under the Fair Labor Standards Act.¹ This signals a DOL that’s thinking creatively about expanding access to benefits, not just regulating existing ones.

At National Integrative Health, we welcome any effort to bring sunlight into the prescription drug supply chain. Transparency paired with actionable, multi-lever solutions is how we drive real savings for employers and better outcomes for their members.

The information age is finally reaching pharmacy benefits. It’s about time.

Jake Velie is Chairman & CEO of National Integrative Health, a managed services organization headquartered in West Des Moines, Iowa, specializing in prescription drug cost optimization for employer health plans.

Footnotes

¹ Bell, Allison. “DOL Secretary Nominee Calls PBM Transparency a ‘Priority.'” BenefitsPro, July 17, 2026. https://www.benefitspro.com/2026/07/17/dol-secretary-nominee-calls-pbm-transparency-a-priority/

² U.S. Senate HELP Committee. “Nomination of Keith Sonderling to Be Secretary of Labor.” Hearing recording. https://www.help.senate.gov/hearings/nomination-of-keith-sonderling-to-be-secretary-of-labor

³ Consolidated Appropriations Act of 2021, Pub. L. No. 116-260, Division BB, Title II (Transparency provisions requiring PBM disclosure of rebates, fees, and prescription drug cost reporting by group health plans).

⁴ U.S. Department of Labor, Department of Health and Human Services, and Department of the Treasury. “Transparency in Coverage Final Rule,” 85 Fed. Reg. 72158 (Nov. 12, 2020).

⁵ Bell, Allison. “Brand-New Federal PBM Laws Fuel Fight Over DOL Transparency Regulations.” BenefitsPro, Feb. 4, 2026. https://www.benefitspro.com/2026/02/04/brand-new-federal-pbm-laws-fuel-fight-over-dol-transparency-regulations/

⁶ Bell, Allison. “DOL Secretary Resigns, New Acting Head Has Been Active on Benefits.” BenefitsPro, Apr. 21, 2026. https://www.benefitspro.com/2026/04/21/dol-secretary-resigns-new-acting-head-has-been-active-on-benefits/

⁷ U.S. Department of Labor, Employee Benefits Security Administration (EBSA). https://www.dol.gov/agencies/ebsa

⁸ National Integrative Health. “About Us.” https://www.nationalintegrativehealth.com/

⁹ Magellan Rx Management. “Medical Pharmacy Trend Report: Site of Care Optimization.” Research shows that shifting infusion administration from hospital outpatient departments to physician offices, home infusion, or ambulatory infusion centers can reduce per-administration costs by 40–60%. https://www.magellanrx.com/medical-pharmacy-trend-report/

By Jake Velie, CEO & President, National Integrative Health

Caribou Systems recently published a piece that every self-funded plan sponsor should read: “You’re the Fiduciary. Can You Prove It?” It’s a direct, uncomfortable question, and that’s exactly why it matters.¹

Their argument is simple and correct: ERISA fiduciary compliance isn’t about outcomes. It’s about process. Specifically, can you produce an independent, time-stamped trail showing you were actively verifying your pharmacy benefit spend, catching errors, and acting on what you found? For most plans, the answer is still no.
 

What Caribou Does 

What Caribou Systems does is rare in this industry: they tell plan sponsors the truth about their exposure and then give them the tools to close the gap. Their re-adjudication engine audits 100% of pharmacy claims (not a statistical sample), they conduct 75+ pre-implementation audits annually, and they process over 200 million claims per year.² That’s not a compliance checkbox. That’s a real oversight infrastructure.

Their emphasis on independence is critical. As they correctly point out, PBM-provided reporting, however detailed, is not independent verification. The Consolidated Appropriations Acts of 2021 and 2026 gave plan sponsors the legal standing to demand raw claims data and expanded audit rights, but having data is not the same as having a defensible fiduciary record.³ ⁴ Caribou builds that record.

Where National Integrative Health Fits

At NIH, we view organizations like Caribou as natural allies. Our work operates on a parallel track: while Caribou ensures your PBM is billing correctly, disclosing rebates fully, and applying benefit terms accurately, NIH ensures you’re achieving the lowest possible net cost on every claim in the first place.⁵
 

We deploy a multi-lever approach: 340B pricing across all 50 states, biosimilars delivering 60–80% savings, site of administration optimization reducing infusion costs by 40–60%, variable copay programs for GLP-1s and specialty medications, clinical interventions, and clinical trial program access.⁵ ⁶

These aren’t competing strategies. They’re complementary layers of a complete fiduciary posture. Caribou asks: “Is your PBM doing what they said they’d do?” NIH asks: “Is the PBM model even the best structure for this claim?” Both questions must be answered.

The Litigation Environment Demands Both

Caribou’s article flags the ERISA lawsuits filed against Johnson & Johnson, Wells Fargo, and JPMorgan over health benefit mismanagement.¹ What those cases reveal is that courts don’t just want to see that you caught billing errors. They want to see that you exercised the care of a knowledgeable professional across the entire pharmacy benefit, including whether you explored alternatives to the traditional PBM markup model.
 

A plan that can show both an independent claims audit trail and evidence that it pursued the lowest net cost through multiple sourcing channels is in a fundamentally different position than one relying solely on PBM-provided reports and a broker’s annual review.

Don’t Wait for Regulation

DOL Secretary nominee Keith Sonderling has made PBM transparency a stated priority, and new regulations are in motion.⁷ But as I’ve said before: transparency tells you where the problem is. You still need solutions. The smartest plan sponsors aren’t waiting for regulators to hand them a playbook. They’re building their fiduciary record now, with partners like Caribou handling the audit and verification layer, and organizations like NIH driving the actual cost optimization.

Caribou Systems is doing important work. If you’re a self-funded plan sponsor and you can’t answer the five questions in their article, start there. Then call us to make sure the dollars flowing through that system are optimized from the ground up.

Jake Velie is Chairman & CEO of National Integrative Health, a managed services organization headquartered in West Des Moines, Iowa, specializing in prescription drug cost optimization for employer health plans.

Footnotes

¹ Caribou Systems. “You’re the Fiduciary. Can You Prove It?” MyHealthGuide, July 16, 2026.

² Caribou Systems. Company overview: audits 200 million+ pharmacy claims annually, conducts 75+ pre-implementation audits per year, and provides 100% claims re-adjudication for independent fiduciary documentation. https://www.caribousystems.com

³ Consolidated Appropriations Act of 2021, Pub. L. No. 116-260, Division BB, Title II (Transparency provisions requiring PBM disclosure of rebates, fees, and prescription drug cost reporting by group health plans).

⁴ Consolidated Appropriations Act of 2026 (Expanded audit rights and regulatory obligations for self-funded plan sponsors to act on pharmacy benefit data).

⁵ National Integrative Health. “About Us.” NIH is a managed services organization that deploys a multi-channel approach to achieve the lowest net cost on every pharmacy claim for employer health plans. https://www.nationalintegrativehealth.com/

⁶ Magellan Rx Management. “Medical Pharmacy Trend Report: Site of Care Optimization.” Shifting infusion administration from hospital outpatient departments to lower-cost settings can reduce per-administration costs by 40–60%.

⁷ Bell, Allison. “DOL Secretary Nominee Calls PBM Transparency a ‘Priority.'” BenefitsPro, July 17, 2026.