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Twice-Weekly Briefing
Friday, August 21, 2026
Issue 260821-56
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The MOC Brief
Health policy, priced and translated for self-funded plan sponsors
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In This Edition
Five developments from the past week. Four of them come down to the same question: who actually knows what your plan is paying, and when do you get to see it.
| 1. | Aon projects a 9.5 percent employer cost increase for 2027 | | 2. | Biosimilar switching saved plans thousands and members nothing | | 3. | Epic turns on real time prior authorization five months early | | 4. | A GLP-1 scheme ran on 60 stolen physician identities | | 5. | The PBM fee disclosure rule sits at the White House |
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| 1 · Cost Trend · August 20, 2026 |
| Aon Projects a 9.5 Percent Jump in Employer Health Costs for 2027 |
| Aon published its 2027 projection on August 20, drawing on more than 1,100 U.S. employers covering 7.9 million employees and $135 billion in 2026 health care spend. Costs are projected to rise 9.5 percent next year, pushing average cost above $19,000 per employee. That follows 2026, when employer cost rose 8.8 percent and total plan cost rose 8.3 percent, moving cost per employee from $16,212 to $17,562. Employees absorbed $5,297 of that this year, $3,130 through paycheck premiums and $2,167 out of pocket, and their out-of-pocket cost grew 10.2 percent against a 6.4 percent rise in premium contributions. Aon calls 2027 the fourth consecutive year of trend approaching double digits, and names rising utilization, chronic conditions, high-cost claims, specialty drugs, GLP-1 therapies, and provider adoption of AI-supported clinical documentation as the drivers. |
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MOC Perspective
A 2027 budget built on a single-digit assumption is already wrong, and this is the fourth straight year that has been true. The number worth studying is the split. Your employees' out-of-pocket cost grew 10.2 percent while their premium share grew 6.4 percent, which means last year's cost shift landed at the point of care rather than in the paycheck. Shifting again in 2027 buys you less than it did in 2024, and it buys it from people who are already paying $5,297.
What to do now
| ▪ | Rebuild your 2027 budget on a 9.5 percent trend, then model an 11 percent case. | | ▪ | Pull your own 2026 out-of-pocket data and compare its growth rate against the 10.2 percent benchmark before you touch deductibles. | | ▪ | Put a dollar figure on the three drivers you can actually price, specialty drugs, GLP-1 therapies, and high-cost claims, and get it into your renewal file by October 1. |
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| Source: Aon |
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| 2 · Pharmacy Spend · August 20, 2026 |
| Biosimilar Switching Saved Plans $1,088 Per Infusion and Members Zero |
| A study in the August issue of The American Journal of Managed Care tracked 1,785 commercially insured patients who switched infliximab products between 2015 and 2021, using the Merative MarketScan Commercial Claims and Encounters Database. Ninety-two percent, or 1,642 patients, moved from the originator to a biosimilar, 72 percent of them to infliximab-dyyb, and 13 percent switched two or more times. Payer savings peaked in 2019 at a median $1,088 per infusion and $189 per vial. By 2021 that had fallen to a median $61 per infusion and $13 per vial, with interquartile ranges crossing into negative territory. Median patient out-of-pocket savings stayed at $0 across the entire study period. |
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MOC Perspective
You paid for the switch in member disruption and got a savings curve that flattened inside two years, while the member who changed drugs got nothing back. If your PBM still reports biosimilar conversion as a savings line, ask for the number per infusion and per year rather than a program total. When the member's cost share never moves, the switch is a rebate transaction, not a cost reduction, and you should price it that way.
What to do now
| ▪ | Ask your PBM for biosimilar savings by year and by unit, per infusion and per vial, for the last three plan years. | | ▪ | Check whether your plan design passes any biosimilar savings to the member at the point of service, and price a lower coinsurance tier for biosimilars. | | ▪ | Add a clause to your next PBM contract that reprices biosimilar economics annually instead of only at renewal. |
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| Source: The American Journal of Managed Care |
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| 3 · Prior Authorization · August 17, 2026 |
| Epic Turns On Real Time Prior Authorization Checks Five Months Early |
| Epic announced on August 17 that four health systems and a group of payers went live with real time prior authorization checks built on the Coverage Requirements Discovery API. Ochsner Health, Froedtert ThedaCare Health, Denver Health, and Summit Health are the live systems. UnitedHealthcare, Network Health, and Aetna are live on the payer side, and sixteen more insurers are testing. Clinicians now see whether a service needs prior authorization while they are placing the order, which removes the phone call, the fax, and the retyping into a separate insurance portal. Federal interoperability rules require payers to support the API by January 1, 2027, and this group went live more than five months ahead of that date. |
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MOC Perspective
The January 1 requirement binds Medicare Advantage, Medicaid, CHIP, and exchange plans. It does not bind your self-funded plan, and that is exactly why this matters. The carrier administering your plan is building the connection anyway for its regulated book, so the only question is whether your ASO contract asks for it. If you do not put it in writing, you will fund the build through your administrative fee and watch it serve someone else's members.
What to do now
| ▪ | Ask your carrier or TPA in writing whether it is one of the sixteen insurers testing the Coverage Requirements Discovery API, and when self-funded books get access. | | ▪ | Add real time prior authorization checking to your 2027 ASO renewal requirements with a named go-live date attached. | | ▪ | Measure your current prior authorization turnaround in days now, so you have the baseline you will hold the vendor to. |
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| Source: Epic |
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| 4 · Pharmacy Integrity · August 17, 2026 |
| A GLP-1 Scheme Ran on 60 Stolen Physician Identities and 3,329 Phone Calls |
| Federal prosecutors in the Southern District of New York charged Rodney Greer, 51, of Illinois on August 17 with wire fraud, health care fraud, and two counts of aggravated identity theft. Between January 4, 2023 and March 9, 2026, Greer allegedly stole the names and National Provider Identifier numbers of roughly 60 physicians across about 19 states, then called approximately 261 pharmacies on approximately 3,329 occasions posing as a licensed prescriber. Prosecutors say he took payment from customers who wanted GLP-1 and other prescription drugs without a physician evaluation, and that the scheme redeemed hundreds of thousands of dollars in health care plan benefits. The case sits before U.S. District Judge Arun Subramanian. Greer was arrested in Chicago on June 17, 2026. |
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MOC Perspective
No corrupt prescriber was required here, only a pharmacy that never verified who was on the phone. Those fills reach your paid claims file looking ordinary, carrying a real NPI, a real drug, and a real member. GLP-1s are the fastest growing line in most plans, which makes them the place where a weak prescriber check costs you the most and shows up the latest.
What to do now
| ▪ | Ask your PBM in writing what prescriber validation it runs at the point of dispense on GLP-1 fills. | | ▪ | Query your last 12 months of GLP-1 claims for prescribers who are out of state, outside the expected specialty, or writing at unusual volume. | | ▪ | Require your PBM to report GLP-1 claims by prescriber NPI in the quarterly package, not by drug alone. |
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| Source: U.S. Department of Justice |
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| 5 · PBM Transparency · August 20, 2026 |
| The PBM Fee Disclosure Rule Sits at the White House With a September Target |
| The Department of Labor's final rule on pharmacy benefit manager fee disclosure, RIN 1210-AB37, has been under review at the Office of Information and Regulatory Affairs since July 23, 2026, and it was still pending on the August 20 review list. The Unified Agenda entry lists September 2026 as the projected final rule date and flags the rule economically significant. The proposal published January 30, 2026 at 91 FR 4348, the comment period was extended on March 2, and comments closed April 15. The rule implements section 12 of Executive Order 14273. As proposed, covered service providers would disclose direct compensation from the plan along with manufacturer payments, spread compensation, pharmacy claw backs, and price protection arrangements, first before contract entry or renewal and then semiannually based on amounts actually received, with audit rights for plan fiduciaries. |
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MOC Perspective
If this lands in September, the next PBM contract you sign is the one it touches. The proposal follows the shape of retirement plan service provider disclosure, which means undisclosed compensation stops being a negotiating point and becomes a prohibited transaction. Sponsors who wait for an effective date will renegotiate against a deadline instead of ahead of one, and PBMs know exactly how that changes the conversation.
What to do now
| ▪ | Pull your current PBM contract and mark every place compensation is described as a range, a category, or not at all. | | ▪ | Ask your PBM now for a written schedule of manufacturer payments, spread, claw backs, and price protection amounts actually received on your plan in 2025. | | ▪ | Write audit rights and semiannual compensation reporting into any PBM contract you sign before the rule is final. |
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| Source: Office of Information and Regulatory Affairs |
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The Bottom Line
Four of these five stories come down to the same gap: your plan pays a price, and someone else knows what it is. Aon can price the trend but cannot tell you which of your dollars moved. The biosimilar data shows a savings line a plan booked and a member never saw. Real time prior authorization exists today, and whether your plan gets it depends on what you wrote into an ASO contract. Only the PBM rule carries a deadline, and September is roughly one contracting cycle away. Ask for the numbers now, while asking is still a negotiation rather than a compliance response.
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Jude Odu
Founder and Principal, Model Optimal Care
Author of Model Optimal Care: End U.S. Healthcare Waste, One Health Plan at a Time
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