Five Non-Negotiables to Control Employer Pharmacy Benefit Costs in 2026

If We Keep Paying for It, It Isn’t “Unsustainable”

For years, employer sponsored pharmacy benefits have been described as broken, unsustainable, and on the brink. Yet spending continues to rise, contracts renew quietly, and the same incentives remain intact. At some point, we have to admit that what we’ve built is working exactly as designed, just not for plan sponsors or plan members.

Now, with pharmacy spending approaching 30 percent of total healthcare costs and still climbing, more employers are realizing that passive concern isn’t a strategy. If 2026 is going to look any different, it requires a fundamentally different posture toward pharmacy benefits, one rooted in engagement, accountability, and long term stewardship.

Pharmacy Benefits Can’t Be Managed from the Sidelines

No employer accidentally ends up with an optimized pharmacy benefits plan.

The organizations that make progress are the ones that stop treating pharmacy as something that can be fully delegated to a broker, a PBM, or a single overstretched HR leader. Real change starts when pharmacy becomes an enterprise level priority, with visibility and support from the C suite.

That doesn’t mean becoming an expert in drug pricing mechanics or rebate guarantees. It means understanding enough to ask the right questions, challenge vague answers, and make informed tradeoffs. It means recognizing that pharmacy is no longer a line item, it’s a strategic lever affecting cost, access, equity, and health outcomes.

Without that internal ownership, even the most well intentioned partners are operating without a compass.

Incentives Matter More Than Promises

One of the most persistent drivers of rising drug spend isn’t drug innovation itself, it’s misalignment.

In the pharmacy ecosystem, incentives often point in directions that are invisible to plan sponsors but highly influential behind the scenes. Rebate structures that favor higher list prices. Formularies optimized for revenue instead of value. Advisors compensated in ways that quietly conflict with their stated role.

Addressing this doesn’t require cynicism, but it does require scrutiny.

Plan sponsors should understand how every major partner gets paid and whether that compensation improves or undermines plan performance. If a vendor’s financial upside depends on higher utilization, higher prices, or opaque revenue streams, that’s not a philosophical issue, it’s a structural one.

Alignment isn’t about trust alone. It’s about design.

A Plan That Works on Paper Isn’t Enough

It’s surprisingly easy to design a pharmacy benefit that looks efficient in a spreadsheet and fails the people it’s meant to serve.

Members experience pharmacy benefits at the counter, on the phone, and in moments of stress, not through utilization reports or trend summaries. When plans don’t reflect how members actually navigate their medications, costs rise in quieter but more damaging ways, abandonment, nonadherence, delayed care, avoidable complications.

Employers who make progress are the ones who actively listen. They ask where friction exists, what medications are hardest to afford, and where confusion is undermining adherence. Just as importantly, they recognize that engagement isn’t a once a year survey, it’s an ongoing conversation.

When members are treated as partners rather than passive recipients, benefits become more effective and more efficient at the same time.

Pharmacy Strategy Is Bigger Than the PBM Contract

It’s tempting to believe that fixing pharmacy benefits starts and ends with selecting the right PBM.

PBM procurement matters, but it’s only one piece of the equation. A pharmacy strategy that truly improves outcomes also includes clinical services designed to help members use medications safely and effectively.

This is where pharmacist led interventions make a measurable difference. Comprehensive medication management helps identify unnecessary therapy, duplications, and opportunities to optimize treatment. Pharmacogenomic testing reduces trial and error prescribing and adverse events. Chronic disease management programs support members living with conditions like diabetes or hypertension over time, not just at refill intervals.

These aren’t add ons. They’re investments that shift pharmacy from a cost center to a clinical asset.

Oversight Is the Missing Muscle

Many employers don’t lack good intentions, they lack visibility.

Once contracts are signed, pharmacy benefits often operate in the background until renewal season arrives. That gap is where waste accumulates and accountability fades. Ongoing oversight changes that dynamic.

Clear performance expectations, defined metrics, and regular reviews turn vendor relationships into active partnerships. Whether it’s biosimilar adoption, program outcomes, or member engagement results, data should be shared, reviewed, and acted upon.

And when expectations aren’t met, course correction shouldn’t feel adversarial. It should feel expected.

Where This Leaves Us

Pharmacy benefits are complex, but they aren’t beyond repair.

What’s required isn’t perfection or omniscience, it’s commitment. Commitment to engagement. Commitment to alignment. Commitment to designing benefits that work in the real world. Commitment to oversight that doesn’t disappear after signatures are collected.

If we keep paying for the same outcomes, we’re choosing them. 2026 can be different, but only if employers decide to stop calling the system unsustainable and start managing it like the fiduciary responsibility it is.

Happy New Year’s Eve, and here’s to doing this differently in the year ahead.