The Evolving Rx Ecosystem: Oral GLP-1s, DTC Disruption, Fiduciary Litigation, and AI

Four Developments Quietly Redefining Pharmacy Benefits in 2026

The pharmaceutical supply chain and the pharmacy benefit ecosystem are constantly in motion. Pricing, access, regulation, manufacturer strategy, technology, it’s all interconnected. The challenge is that while these pieces influence one another, they rarely move in a clean, linear way. Instead, changes tend to show up in fragments, scattered across press releases, earnings calls, policy announcements, and legal filings. Keeping track of what actually matters, and how it fits together, isn’t easy.

Because of that, something I try to intentionally build into my pharmacy-focused writing, at least once a month, is a checkpoint. A space to step back from any single topic and instead summarize a handful of developments I’ve been reading about, thinking through, and discussing behind the scenes. The goal isn’t to predict the future or offer definitive answers, but to connect dots, share perspective, and surface the practical implications that plan sponsors, consultants, and pharmacy leaders may want to keep in the back of their minds.

This post is one of those checkpoints.

Below are four developments from early 2026 that, in my view, signal where pharmacy benefits are heading. None of them exist in isolation. In fact, what makes them notable is how tightly they intersect, with pricing, fiduciary responsibility, benefit design, and operational execution.

1. Oral Wegovy and the Quiet Redefinition of GLP-1 Economics

Every so often, a product launch changes the conversation, not because it introduces a new class of therapy, but because it removes an assumption we didn’t realize we were relying on.

That’s what the arrival of oral Wegovy represents.

For the first time, an FDA-approved oral GLP-1 for weight management is delivering outcomes comparable to injectable formulations. From a clinical standpoint, that alone is meaningful. But from a pharmacy benefit perspective, the delivery mechanism may be the more disruptive feature.

Oral formulations eliminate cold-chain complexity, reduce manufacturing friction, and expand distribution pathways. Unsurprisingly, pricing follows. When self-pay options for an oral GLP-1 sit hundreds of dollars below traditional injectable list prices, it forces a reexamination of what we’ve come to accept as “normal” GLP-1 economics.

That doesn’t mean management becomes easier. Daily dosing introduces adherence variability that weekly injections avoid. Administration requirements may affect persistence. And utilization management approaches designed around specialty injectables don’t translate cleanly to retail oral therapy.

Still, the broader signal is hard to ignore. If outcomes can be delivered without specialty infrastructure, the long-term pricing trajectory of GLP-1s is likely to change, especially as additional oral competitors approach the market.

2. Manufacturer Direct-to-Consumer Models Are No Longer Experimental

Direct-to-consumer (DTC) initiatives from drug manufacturers have been on the periphery for a while, interesting to observe, but rarely urgent enough to disrupt traditional pharmacy benefit management. That dynamic is shifting rapidly.

Eli Lilly arguably led the charge with LillyDirect in 2024, creating one of the first structured DTC channels for their GLP-1 products. By bypassing intermediaries across the benefit continuum, PBMs, insurers, and sometimes even pharmacies, they were able to offer plan members both simpler access and lower out-of-pocket pricing. This move set a precedent, prompting other manufacturers to launch their own DTC programs, each experimenting with cash-pay models and streamlined fulfillment.

Fast-forward to early 2026, and these efforts have become structurally significant. The federal government is now supporting the movement with TrumpRx, a platform designed to help patients access manufacturer DTC offerings directly, while simultaneously aligning with broader efforts like Most-Favored-Nation pricing to make medications more affordable.

The practical result is a two-market reality. In one lane, medications continue to flow through the traditional benefit, subject to formulary rules, step therapy, and negotiated pricing. In the other, members can bypass coverage entirely, paying cash directly to manufacturers, often at lower cost, but leaving the plan blind to utilization, adherence, and clinical patterns. Deductibles and out-of-pocket accumulators may no longer capture these purchases, and traditional prior authorization or step therapy protocols become largely irrelevant.

For plan sponsors, the question is no longer whether DTC models matter, but how to manage them. Do they complement existing benefits and improve member access, or do they quietly erode plan oversight, governance, and cost management? The answer may shape pharmacy strategy well beyond 2026.

3. Fiduciary Litigation Is Expanding Beyond Retirement Plans

If the last decade taught employers anything, it’s that fiduciary risk doesn’t stay confined to retirement plans forever.

Recent litigation suggests health and welfare benefits, particularly voluntary benefits, are moving into the spotlight. What’s notable isn’t just that employers are being sued, but that benefits consultants and brokers are being named alongside them.

The allegations are familiar: failure to monitor fees, failure to evaluate alternatives, and compensation structures that may influence recommendations in ways participants never see.

Healthcare-related ERISA cases have so far been decided largely on procedural grounds rather than substance. But that shouldn’t be mistaken for a lack of risk. Voluntary benefits cases may present a clearer path by tying alleged harm directly to premium payments, rather than downstream medical costs.

For plan sponsors, the lesson isn’t to assume liability, it’s to assume scrutiny. Governance practices that became standard in retirement plans, formal committees, regular RFPs, fee benchmarking, and documented decision-making, are increasingly relevant across the broader benefits landscape.

4. Healthcare AI Has Shifted From Curiosity to Infrastructure

The healthcare AI conversation changed this year not because of flashy demos, but because of integration.

New platforms are being built with healthcare workflows in mind, coverage databases, coding systems, interoperability standards, and compliance constraints baked in from the start. For managed care pharmacy, this translates into tangible use cases: faster prior authorization review, more structured appeals, automated coverage checks, and scalable communication triage.

This isn’t about removing humans from decision-making. It’s about reducing the administrative drag that consumes pharmacist and clinician time without adding clinical value.

The risks remain, privacy, hallucinations, overreliance, but the more mature platforms are acknowledging those limits explicitly. Human oversight isn’t optional; it’s foundational.

At this point, the question is less whether AI belongs in pharmacy operations and more how intentionally organizations choose to adopt it.

Closing Thoughts

None of these developments on their own define the future of pharmacy benefits. But together, they tell a consistent story.

• Manufacturers are rethinking how drugs are delivered and sold.

• Members are finding ways around traditional benefit structures.

• Litigation is raising expectations for fiduciary rigor.

• Technology is reshaping how administrative work gets done.

For plan sponsors and those who advise them, this environment rewards clarity and discipline. Documented processes, transparent vendor relationships, regular benchmarking, and thoughtful adoption of new tools are no longer “nice to have.” They are becoming baseline requirements.

These monthly checkpoints aren’t about reacting to every headline. They’re about recognizing patterns early, before they show up as cost overruns, operational gaps, or legal exposure.

And as always, the goal is to leave you not just informed, but thinking.