How can healthcare businesses navigate PBM reform?

Medication intelligence: Building an infrastructure for US drug pricing

Medication intelligence is the new infrastructure of trust.

The modern drug pricing and clinical ecosystem that is emerging from PBM reform requires more than raw data to support responsible medication decision-making. It requires expert-reviewed evidence and drug data that is context-aware and embedded within medication workflows.

For the commercial healthcare ecosystem, medication intelligence goes beyond just a dataset to become defensible infrastructure:

• Evidence-aligned data and advanced applications like AI are now a strategic requirement: Transparency means every price, classification, and clinical attribute must be explainable and repeatable. AI can support this at scale, but only when its output is consistent and grounded in validated data. Fragmentation or unconstrained generative models increase risk, inconsistency, and cost.
• Fragmented or generalized data will fail under transparency pressure: Inconsistent NDC (National Drug Code) mapping, incomplete benchmarks, outdated classifications, or uncontextualized data lacking metadata tagging become liabilities in a world of audits, public reporting, and cost-plus models.
• Robust, enterprise-level governance gives a competitive advantage: Appropriate and confident drug decisions must optimize both the care quality and financial opportunities presented by PBM reform. In a transparent market, those decisions will rely on defensible data lineage, expert curation of data, and structured updates.
• Consistent medication information reduces variation at scale: Alignment across claims, formularies, dispensing, analytics, and care can reduce friction, errors, and mispricing, while enabling performance-based insights.
• A unified medication foundation elevates every decision-maker: Manufacturers, health plans, PBMs, pharmacies, and digital health platforms all rely on the same medication truths. When key players are accessing aligned data and evidence to support those decisions, everything built atop them becomes more reliable, stable, and scalable.

Turning PBM reform into opportunity: Five business scenarios

To keep patients and members safe without sacrificing efficiency or profit, healthcare businesses need consistent drug data to help align decision-making and communication between players across the ecosystem. PBM reform introduces distinct opportunities for each participant in the commercial healthcare landscape.

1. Retail pharmacies: New transparency requirements are a long-awaited break

Increased PBM reimbursement transparency, and the accompanying data it will surface, offer retail pharmacies a more solid negotiating position and long-awaited opportunities to increase operating margins. Fewer retroactive fees and reduced risk of pharmacy network exclusion – especially for rural and independent pharmacies – will help pharmacies improve cash-flow predictability.

What’s next for retail pharmacies?

• Prepare operationally for upcoming PBM contract amendments and/or renegotiations.
• Plan for managing changes in reporting requirements to assist PBMs in meeting their new transparency requirements.

2. Pharmacy platforms and technology-enabled care: Defensible data supports scalability

For healthcare technology companies, PBM reforms may bring about new concerns they’ve never had to consider before. Heightened scrutiny of pricing and dispensing practices may require technology developers to plan ahead on how they will demonstrate high-quality data governance to their customers. Direct-to-consumer models will be reviewed on pricing accuracy, labeling, and medication counseling. Some vendors may face new challenges, such as requirements to disclose prices and fees and an increased risk of audits.

Expert-reviewed medication intelligence, including access to a variety of pricing methodologies, provides the defensible data backbone technology platforms need to demonstrate consistency across dispensing systems, formularies, and consumer-facing prices, helping them maintain trust with regulators and consumers.

What’s next for health tech companies?

• Leverage context-aware drug data to scale operations while adhering to new regulations.
• Build systems that integrate structured, evidence-aligned medication intelligence to help bolster the clinical foundation of solutions, taking platforms beyond convenience to a more complete offering that supports evolving customer decision-making needs.

3. Payers: A new era of formulary accountability

Shifting dynamics around net price plan designs and rebate passthroughs are reshaping payer-PBM relationships. Transparency in formulary design and cost-management decisions will help payers build more effective, accountable partnerships. At the same time, increased PBM reporting places a greater analytical burden on payers, who will need the ability to leverage additional pricing methodologies in their analytics and formulary considerations and must now demonstrate measurable cost and quality improvements to employers and regulators.

What’s next for payers?

• Use evidence-based medication intelligence and leverage additional pricing methodologies to help reduce variation, enhance outcomes, and drive value-based medication management.
• Focus on contract and network management analytics to inform drug-spend management, formulary changes, and clinical intervention programs. Aligning workflows with trusted, expert-reviewed drug data helps strengthen that decision-making.

4. PBMs: Intermediaries redefined as transparent service providers

PBMs face significant operational changes, margin compression, and intensifying competition. To differentiate, many will expand services such as specialty care management, drug-intensive health services and care programs, and member support—all of which require robust drug data. PBMs are also likely to rethink coverage and benefit design, which may include prior authorization, limits, and formulary inclusion.

PBMs that can help health plans stay compliant with minimal friction — via dashboards, automated reporting, and clean data governance — will prove themselves extremely valuable. Drug knowledge bases that have the capability to function in contextual workflows and offer validated data to support value-set management and creation of code groups will be key to supporting advanced analytics.

What’s next for PBMs?

• Invest in defensible, expert-curated drug data to maintain relevance and differentiation, such as demonstrating comparative effectiveness of drugs selected for formularies.
• Use medication intelligence with reporting and analytics capabilities to build trust and show value to stakeholders.

5. Consultants and analysts: Leveraging evidence to accelerate the value of insight

Consultants will uncover new opportunities in the growing demand for deeper insights from third-party analysts to guide clients through these changes. With this potential for growth, there may also be increased pressure on analysts to find and demonstrate value for clients while holding PBMs and payers accountable to new reforms. Consultants will need to enhance their understanding of the role of structured drug data in healthcare decision-making to deliver analyses for clients.

What’s next for consultants?

• Leverage evidence-based medication intelligence to deliver actionable, data-driven recommendations.
• Stay nimble by understanding how to use different pricing methodologies and incorporating them into analyses.

Medi-Span drug data: Prepare now for PBM legislation impact

PBM reform is not a policy update. It is the beginning of a new pricing architecture in which clarity replaces complexity, evidence replaces estimation, and trusted drug data enables medication intelligence. Organizations that invest now in scalable, cost-effective drug data resources steeped in governance will be prepared to adapt, comply, optimize, and lead.

Medi-Span® drug data and pricing analysis tools offer stakeholders across the healthcare ecosystem the medication intelligence they need to navigate these changes and thrive in a rapidly evolving healthcare landscape. Evidence-based, expert-reviewed knowledge resources create a strong and reliable data foundation to support pricing, adjudication, formulary, dispensing, and analytics decisions.

Speak with a specialist to evaluate your drug data foundation and understand how to fortify your organization for the transparent, value-aligned future of drug pricing.