October 2, 2026
The Honorable Ron Wyden
Ranking Member, Senate Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510
Re: Request for Information – Health Coverage That Works For Everyone
Dear Ranking Member Wyden and Members of the Senate Finance Committee Minority,
The Pharmaceutical Industry Labor-Management Association (PILMA) welcomes the
opportunity to respond to the Committee’s Request for Information on private insurance
markets. PILMA is a nonprofit coalition of labor unions and biopharmaceutical manufacturers
united by a shared commitment to the workers who build and sustain America’s life sciences
industry and to ensuring those workers have access to the healthcare they have earned. Our
members negotiate health benefits and administer jointly trusteed health plans, which
depend on a functioning, fair insurance market.
When that market fails due to anticompetitive middleman practices, inadequate mental
health coverage, or opaque pricing that conceals where dollars actually go, it is working
families who bear the cost. We offer the following feedback with that perspective in mind.
PILMA’s comments respond principally to what PILMA believes are the most critical aspects
of the RFI’s questions include those contained in Section II regarding network adequacy,
prior authorization, and barriers to care, and in Section III regarding vertical integration,
pharmacy benefit manager (PBM) and third-party administrator (TPA) practices, and
transparency across private insurance markets.
Supply Chain Accountability, Vertical Integration, and Transparency
PILMA supports the Committee’s interest in addressing the harmful impacts of vertical
integration in the insurance industry. When the same corporate parent owns an insurer,
PBM, pharmacy, provider group, or other healthcare business, financial incentives can
influence which medicines are covered, which providers are included in a network, and
where patients are directed to receive care. Greater transparency is needed to ensure these
decisions serve patients rather than an affiliated company’s bottom line.
PILMA has also long raised concerns about the unchecked power of PBMs and other
middlemen in the prescription drug supply chain. Research examining spending on brand
medicines found that more than half of every dollar went to insurers, PBMs, providers, and
other entities in the supply chain.
i Workers, employers, and plan sponsors deserve to
understand where their healthcare dollars are going and whether negotiated savings are
reaching the patients and plans they were intended to benefit.
PILMA applauds the Committee’s bipartisan work on PBM reform as part of the 2026
Consolidated Appropriations Act and encourages Congress to build on that progress. PBM
compensation should not be tied to a medicine’s list price or structured to reward preference
for higher-cost products. This reform should apply beyond Medicare Part D and extend tothe commercial market. To that end, health plans should receive clear information about
rebates, fees, claims, and payments to affiliated companies.
Congress should also address practices that steer patients toward pharmacies or providers
owned by the same company as their insurer or PBM. Patients should be able to use the
provider, pharmacy, or treatment option that best meets their needs rather than being
directed to an affiliated business because it is more profitable for the insurer.
While the CCA was a good step towards requiring disclosure of information that could help
plan fiduciaries evaluate and quantify PBM performance, it still fails to address self-dealing in
a constructive manner. Many of the functions PBMs provide involve discretionary decisions
of the type which meet the definition of fiduciary under ERISA. Determinations of what drugs
should be included on the plan’s formulary, which pharmacies are included in the
participating networks, and what reimbursement rates are paid to such vendors involve
“discretionary authority and discretionary control over management of the Plan” which meet
the definition of fiduciary as promulgated by the Department of Labor.
Service providers are generally not considered fiduciaries, however, in the context of the
PBM industry, the number and variety of such decisions, as well as the complex
relationships within their corporate partners, far exceed that of a typical service provider
making prudent oversight impractical, if not impossible. One practical solution is to require
that PBMs be declared fiduciaries. By doing so, the propensity towards steering customers,
manipulating participating pharmacy networks to favor related corporations and constructing
formularies based on higher list prices would be prohibited.
Similarly, transparency principles like those contained in the CCA should apply to TPAs
serving self-insured and jointly-trusteed health plans. These plans should have ready access
to their own cost and claims data, a clear accounting of fees, compensation, and payments
made to affiliated companies. That transparency would help ensure that the Taft-Hartley
plans on which many PILMA members rely are using healthcare dollars in the best interests
of workers and their families.
Mental Health Access, Network Adequacy, and Parity
Mental health is among the most urgent and personal illustrations of why a functioning
insurance market matters. The construction sector has one of the highest suicide rates of
any industry in the country – male construction workers die by suicide at a rate 65% higher
than the average U.S. male worker.ii PILMA has made mental health a cornerstone of our
work, bringing together our industry and union partners to provide support and resources to
our members.
Despite federal parity requirements, workers and their families continue to encounter
significant disparities in access to in-network mental health and substance use disorder
services. Inadequate networks can mean longer waits, fewer available appointments, and
higher costs when workers have no choice but to seek care outside their plan’s network. An
analysis of four large commercial insurers found disparities between access to in-network
mental health and substance use disorder care and access to physical health care in 43
states.
iii
The Department of Labor’s September 2026 guidance on parity enforcementiv appropriately
focuses enforcement on treatment restrictions, prior authorization, and network adequacy.PILMA encourages the Committee to build on that framework by requiring plans to maintain
adequate behavioral health networks, keep provider directories current, and demonstrate
that workers can obtain timely in-network care. These commonsense protections would
provide workers with greater confidence that their coverage will connect them to care when
they need it.
PILMA also encourages Congress to examine prior authorization, step therapy, and other
insurance practices that unnecessarily delay mental health or substance use disorder
treatment. Plans should apply these requirements fairly and consistently, clearly explain
adverse coverage decisions, and provide patients with timely appeals when care is denied.
These protections should apply across both the fully-insured and self-insured markets.
The workers who build America’s life sciences facilities have earned their healthcare benefits
through hard work and collective bargaining. They deserve an insurance market that works
for them and their families. PILMA stands ready to serve as a constructive partner as this
work advances, and we would welcome the opportunity to provide additional detail at the
Committee’s convenience.
Respectfully submitted,
AJ Stokes
–
Executive Director,
Pharmaceutical Industry Labor-Management Association
i Berkeley Research Group. The Pharmaceutical Supply Chain, 2013–2023. January 2025.
stakeholders/
ii Suicide Rates by Industry and Occupation — National Violent Death Reporting System, 32 States, 2016
https://www.cdc.gov/mmwr/volumes/69/wr/mm6903a1.htm
iii The Kennedy Forum. New insurer data reveals significant gaps to in-network mental health care and treatment for
substance use disorders when compared to physical health. April 14, 2026.
health-care-and-treatment-for-substance-use-disorders-when-compared-to-physical-health/
iv U.S. Department of Labor. Guiding Principles for EBSA’s Enforcement of the Mental Health Parity and Addiction
Equity Act’s Nonquantitative Treatment Limitation Requirements. September 8, 2026. https://beta.dol.gov/policy-
regulations/reference-materials/guidance-searches/ebsa-field-assistance-bulletin-no-2026-03