Healthcare providers now have instant access to prescription drug prices and insurance coverage information right at the point of care.

What the New HHS Prescription Drug Rule Does

The final rule enables healthcare providers using certified health IT systems to:

• Submit prior authorizations electronically for faster approval decisions
• View drugs covered by a patient's health insurance in real-time during appointments
• Exchange electronic prescription information directly with health plans and pharmacies
• Compare drug prices and out-of-pocket costs before writing prescriptions

This means doctors can now see whether a prescribed medication requires prior authorization, costs $10 or $500, and identify covered alternatives during a patient visit.

When Does the HHS Prescription Drug Rule Take Effect?

Effective Date: October 1, 2025

Healthcare organizations must ensure their health IT systems meet certification requirements by October 1, 2025 to take advantage of these new capabilities.

Understanding HTI Certification Requirements

To qualify as a certified health IT system under this rule, healthcare providers must follow a series of Health Data, Technology, and Interoperability (HTI) regulations. The timeline ran from December 2023's HTI-1 through July 2025's HTI-4.

While this certification requirement does not fall on employers, it's worth understanding because it affects which providers in your network can offer these benefits to your workforce.

Who Is Affected by the HHS Prescription Drug Rule?

This rule impacts multiple stakeholders in employer-sponsored health plans:

• Healthcare providers who prescribe medications and use electronic health record (EHR) systems
• Health insurance carriers and TPAs that administer your group health plan
• Employees and their dependents who will gain transparency into prescription costs before leaving the doctor's office
• Health IT vendors who provide EHR systems to healthcare providers
• Pharmacies that exchange electronic prescription data with providers and payers

Understanding which parties are responsible for implementation helps employers know what to expect and when to follow up with health plan administrators.

Key Benefits for Employer-Sponsored Health Plans

1. Accelerated Electronic Prior Authorization

Electronic prior authorization built on CMS requirements allows providers to submit authorization requests digitally using certified health IT systems. This results in:

• Faster care authorization decisions
• Reduced phone calls and fax communications with insurance companies
• Greater transparency about approval status and requirements
• Less treatment delay for patients

2. Improved Drug Cost Transparency

Real-time price comparison tools enable prescribers to:

• View actual drug costs during patient encounters
• Identify lower-cost alternatives covered under a patient's insurance
• Make cost-effective prescribing decisions on the spot
• Help patients avoid sticker shock at the pharmacy

This feature is particularly valuable for employees covered under Medicare Part D, who often face complex formularies and cost-sharing structures.

3. Significant Burden Reduction

According to HHS, improvements in workflow automation and transparent decision-making have the potential to:

• Save millions of hours of clinician time annually
• Reduce billions of dollars in administrative labor costs
• Allow clinicians to spend more time with patients and less time on paperwork

Action Steps for Employers

While you're not directly responsible for implementing this rule, there are practical steps to maximize its benefits:

1. Connect with Your Health Plan Provider

Ask your carrier or third-party administrator (TPA) about their readiness for real-time benefit exchange:

• When will this capability be live for your plan?
• Which providers in your network have certified systems?
• How will this affect prior authorization processing times?

2. Plan to Send Employees Communications

Once your health plan confirms participation, let your workforce know about this improvement. Consider including updates in:

1. Benefits newsletters
2. Open enrollment materials
3. Your employee benefits portal

Your employees will appreciate knowing they can expect faster authorizations and upfront cost information.

3. Monitor the Impact

After October 1, 2025, track whether you see:

• Faster prior authorization turnaround
• Improved medication adherence rates
• Fewer complaints about prescription cost surprises
• Better generic utilization

These metrics can inform your benefits strategy and give you leverage in negotiations with health plan partners.

4. Factor This Into 2026 Benefits Planning

As you plan for next year's benefits, consider how real-time prescription transparency might affect:

• Your pharmacy benefit plan design
• Prior authorization policies
• Employee education strategy
• Potential cost savings from better medication adherence

Frequently Asked Questions

When does the HHS prescription drug transparency rule take effect?

The final rule takes effect on October 1, 2025. Healthcare providers using certified health IT systems can begin accessing real-time prescription drug information on this date, benefiting employees covered under employer-sponsored health plans.

Do employers need to take action to comply with the HHS prescription drug rule?

No. This rule applies to healthcare providers and health plans, not employers directly. However, employers should communicate with their health plan administrator about readiness and implementation timelines to understand how this will benefit their workforce.

Will the HHS prescription drug rule reduce employer healthcare costs?

The rule has the potential to reduce costs through improved medication adherence, increased generic drug utilization, and system-wide efficiency improvements. Your specific cost impact will depend on your health plan's participation, pharmacy benefit design, and employees' prescription utilization patterns.

Do all health insurance plans have to participate?

The rule builds on existing CMS requirements for certain payers, particularly Medicare Part D plans. Healthcare providers should verify participation status with individual health plans and payers.

What if our health plan or TPA isn't ready by October 1, 2025?

Contact your health plan administrator or TPA to ask about their readiness timeline and which capabilities will be available to your employees.

How does this affect employer pharmacy benefit plan design?

This rule doesn't require changes to your pharmacy benefit plan design. However, it creates an opportunity to review your pharmacy benefits strategy, especially around prior authorization policies, formulary design, and cost-sharing structures. Consider discussing optimization strategies with your benefits consultant.

Does this rule apply to self-funded employer health plans?

Yes. While the rule primarily regulates healthcare providers and health IT systems, the benefits extend to employees covered under both fully insured and self-funded health plans. Employers with a self-funded plan should work with their TPA to understand implementation timelines.

The Bottom Line

The HHS final rule on real-time prescription drug access represents meaningful progress toward healthcare transparency. For employers, the benefits are straightforward: your employees get faster care, better cost visibility, and fewer frustrating surprises at the pharmacy counter.

While implementation falls on healthcare providers and health plans, staying informed helps you advocate for your workforce and make smarter benefits decisions. Reach out to your health plan provider about their readiness and consider how you'll communicate these improvements to your employees.

Better medication adherence, faster treatment, and improved cost management all support your goals of maintaining a healthy, productive workforce while managing healthcare costs effectively.

Have questions about how the prescription drug transparency rule affects your benefits strategy? Contact OneDigital today to ensure your organization is prepared.