Big changes are coming to the way prescription drug benefits work, and it’s great news for patients, providers, and employers alike.
On September 2, 2025, the Department of Health and Human Services (HHS) released a final rule that advances real-time prescription price transparency and significantly streamlines the prior authorization process for medications. These changes are designed to help patients better understand their out-of-pocket costs before they get to the pharmacy counter, and they also support employers in offering more transparent, tech-forward health benefits.
What’s Changing?
Under this new rule, group health plans that offer prescription drug coverage must adopt modern technology standards that:
- Provide real-time prescription benefit information – Patients and providers will be able to see exactly how much a prescribed drug will cost based on the patient’s insurance coverage, including deductibles, copays, and any out-of-pocket maximums reached to date.
- Show lower-cost alternatives at the point of care – The system will offer real-time comparisons across various pharmacies and medications, giving patients the option to choose more affordable alternatives if available.
- Speed up prior authorizations – Through the use of API-based technology, the rule streamlines prior authorization requests, allowing for faster decisions that can be completed while the patient is still in the provider’s office.
Why This Matters: The Power of Real-Time Cost Sharing
This rule is part of the broader Consolidated Appropriations Act of 2021 (CAA-21) initiative to make healthcare more transparent, affordable, and accessible. One of the key goals is to ensure that patients aren’t left guessing about whether a drug is covered or what it will cost them.
With these new tools:
- Providers can submit a proposed prescription electronically and receive immediate confirmation of whether it’s covered.
- Patients can compare costs across pharmacies and drug alternatives in real time.
Approvals for medications can happen faster, reducing treatment delays and paperwork headaches.
Timeline: When Do These Changes Take Effect?
- The rule goes into effect on October 1, 2025.
- A transition period runs through 2027, giving health plans and providers time to implement the required technologies.
What Employers Should Do Now
If you sponsor a group health plan that includes prescription drug coverage, here’s what you need to know:
- Work with your carriers and claims administrators – Ensure they are preparing to integrate the new real-time APIs and tools needed to comply with the rule. These features should be in development now to meet the transition timeline.
- Plan participant communication is key – Once these new features are available, educate your employees on how to use them. Highlight that they can now view drug pricing and coverage options while still in the doctor’s office, helping them make cost-effective decisions on the spot.
- Monitor compliance milestones – Set internal check-ins with your vendors over the next two years to stay on track for full implementation by 2027.
Bottom Line
This final rule represents a major leap forward in health plan transparency and patient empowerment. With easier access to cost information and quicker approvals, patients can avoid surprises at the pharmacy and take control of their health care decisions.
For employers, this is not just about compliance; it’s an opportunity to deliver a better healthcare experience that aligns with modern expectations. Now is the time to prepare your team with the tools and information they need to make the most of this transparency revolution in prescription drug coverage.