Looking Ahead in Pharmacy Benefits for 2026

What Plan Sponsors Should Be Aware of Their Pharmacy Benefits in 2026

As someone who closely follows the pharmacy benefit industry, through my work, conversations with clients (self-funded employers and health plans), vendors, and broader observation of market behavior, I’ve been watching several trends gain momentum over the past year. Drug pricing pressures are intensifying, regulatory expectations are rising, and both participants and plan sponsors are experimenting with new pathways to manage and access their medications.

And while each of these trends have been developing independently, the way they are now intersecting will make 2026 a pivotal year for pharmacy benefits. So, with that context in mind, here are the major trends shaping the year ahead that I see and what plan sponsors should be paying attention to as they prepare their benefit strategies.

1. Escalating Drug Costs Continue to Outpace Expectations

GLP-1 Utilization Remains a Dominant Driver

GLP-1 medications such as Ozempic®, and Wegovy®, continue to reshape the industry. Their rapid expansion into weight management and prevention has doubled their share of pharmacy spend in two years. With additional GLP-1s expected to enter the market and more indications on the horizon, plan sponsors will face mounting pressure to balance access, outcomes, and affordability.

Rise of High-Cost Specialty and Gene Therapies

Cell and gene therapies are maturing, but their cost profiles remain unprecedented. Nearly 3 in 4 plans expect a significant financial impact over the next 2-3 years. Many employers still lack stop, loss protection, clear contracting pathways, or specialty carve-out models that mitigate exposure.

Biosimilars Are Expanding, But Slowly

While biosimilars can offer 15-35% savings compared to originators, market adoption continues to lag due to limited prescriber familiarity, rebate dynamics, and patient switching concerns. Greater education, better benefit design, and clearer contracting terms will be needed to unlock their potential in 2026.

Tariff and Economic Pressures Add New Uncertainty

The recent 100% tariff on branded and patented pharmaceutical imports (effective October 1, 2025) has the potential to influence upstream pricing and supply chain volatility. Even with legal challenges pending, plan sponsors should expect pricing variability through 2026. At the same time, overall health benefit costs are projected to increase by 6.5%, the steepest rise in more than a decade, with some forecasts warning of double digit inflation driven largely by specialty trends.

Bottom line: Managing trends over time, not just year to year, will be essential. Plan sponsors will need strategies that incorporate clinical management, contracting rigor, and transparent cost controls.

2. Regulation and Transparency Will Shape the New Normal

2026 will likely be a watershed year for PBM transparency.

More than 23 states now have drug transparency laws on the books, and 12 have established Prescription Drug Affordability Boards tasked with monitoring (and potentially capping) prices of high-cost medications.

At the federal level, new HHS rules effective October 2025 require real-time drug pricing information, expanded data-sharing, and streamlined prior authorization workflows. These changes are set to accelerate a shift toward clear, pass-through pricing models.

What this means for plan sponsors: Transparent contracting will no longer be a preference, it will be an expectation. Understanding how your PBM defines contract terms, retains revenue, and aligns incentives will matter more than ever.

3. Members May Shoulder More of the Cost Burden

Despite policy efforts aimed at affordability, members are projected to feel more pressure in 2026.

The $2,000 OOP cap under the Inflation Reduction Act (IRA) provides meaningful protection for Medicare beneficiaries with very high drug costs, but most won’t reach that level and may see premiums or cost-sharing shifts elsewhere in the benefit.

With ongoing cost pressures on employers and commercial payers, higher copays, coinsurance rates, and deductibles are likely. This trend is even more pronounced following the mid-2025 coverage changes that increased churn among Medicare and Medicaid populations.

The takeaway: Benefit designs in 2026 will require delicate balancing across affordability, adherence, and utilization.

4. Consumer Advocacy and Direct-to-Consumer Options Are Accelerating

With higher out-of-pocket costs, consumers are increasingly turning to:

• Pharmacy discount cards

• Manufacturer copay savings

• Patient assistance programs

• Cash-pay or non-insurance options

In 2026, this shift is expected to intensify with the federal launch of TrumpRx.gov, a consumer-direct website promoting manufacturer rebates and discount options outside of traditional pharmacy benefits. While long-term implications remain unclear, the move underscores a growing preference for member-driven price transparency.

Plan sponsors should keep a close eye on:

• Duplicate discounts

• Copay accumulator impacts

• Member leakage outside the benefit

• Data capture challenges

5. Nontraditional, Transparent, and Unbundled Models Gain Momentum

Cost-Plus Pricing Expands

Mark Cuban’s Cost Plus Drugs model has catalyzed broader adoption of acquisition-based pricing. Major chains and benefit partners are piloting or expanding cost-plus offerings that provide visibility into ingredient cost, markup, and dispense fees.

These models offer an alternative to traditional spread pricing, but may require operational adjustments around network access, rebate strategy, and formulary management.

Unbundled PBM Solutions Gain Traction

Roughly 10% of health plans are exploring unbundled models, separating rebate management, formulary development, claims adjudication, specialty pharmacy, and retail contracting. Blue Shield of California’s shift to an unbundled model continues to influence conversations across the industry.

Medical Benefit Specialty Carve-Outs Are Increasing

More than half of pharmacies now live in specialty drugs, many of which are billed through the medical benefit. Carve-out models with dedicated specialty management solutions are gaining traction as plans look for better visibility, utilization control, and contracting leverage.

6. Digital Health, AI, and Data Integration Will Redefine Benefit Management

Although not always highlighted, 2026 will see rapid growth in digital health capabilities:

• AI-driven prior authorization

• Predictive modeling for high-cost claimants

• Specialty-care coordination tools

• Integrated medical/pharmacy datasets

• Digital therapeutics paired with GLP-1s and chronic disease management

As these technologies mature, plan sponsors will have new opportunities, and new risks, around data quality, privacy, and vendor coordination.

7. Specialty Pharmacy Access and Site-of-Care Optimization Will Be Critical

Specialty therapies increasingly require oversight beyond price:

• White-bagging and brown-bagging policy changes

• Site-of-care shifts from hospital outpatient to home infusion

• Narrow networks and limited-distribution drug (LDD) challenges

• Clinical pathway alignment

• Physician-administered drug (PAD) management

Plan sponsors seeking sustainable trend control will need integrated strategies across both the medical and pharmacy benefits.

Preparing for 2026, What Plan Sponsors Can Do Now

As the pharmacy landscape continues to evolve, clarity becomes a differentiator. Plan sponsors should consider:

• Reassessing PBM contract terms and revenue streams

• Understanding how rebates, markups, and spread pricing influence net cost

• Evaluating specialty carve-out vendors or medical drug management solutions

• Reviewing GLP-1 benefit design with a long-term lens

• Exploring cost-plus or transparent acquisition-based pricing options

• Investing in data integration and predictive analytics

• Monitoring upcoming regulatory changes at both state and federal levels

2026 will challenge the status quo, but it also provides an opportunity. With the right strategies, and the right PBM or partner, plan sponsors can maintain affordability, elevate member experience, and strengthen long-term financial sustainability.