As 2025 draws to a close, it’s time to revisit the predictions we shared in our pharmacy benefits trends webinar earlier this year and assess how they’ve unfolded. From fiduciary oversight and biosimilar adoption to legislative reform and PBM accountability, the pharmacy benefits space has seen rapid shifts and unexpected turns. In this follow-up, we’ll explore which trends gained momentum and where surprises emerged. Whether you joined us live or are catching up now, this recap offers a clear perspective on how our forecast aligned with reality.
Prediction #1: Fiduciary responsibility will continue to be an area of potential risk for employers, driving the need for greater focus on pharmacy benefits.
TRUE: The spotlight on fiduciary duty will not fade in the year ahead. While some of the early, high-profile employer lawsuits were dismissed on procedural grounds, they’ve nonetheless heightened awareness of the legal and financial risks tied to pharmacy benefits decisions. From California’s new law that extends fiduciary obligations to PBMs to a surge of new lawsuits targeting plan oversight, the message is clear: employers must manage pharmacy benefits with diligence. Those early case dismissals don’t signal the end of the issue—they’ve simply laid the foundation for sharper, more strategic legal challenges in the future.
Prediction #2: Innovative approaches to pharmacy benefits and strong contracts are essential to achieving market competitiveness for plan sponsors.
TRUE: In our 2025 trend webinar, we emphasized the importance of keeping pharmacy benefit strategies competitive on an ongoing basis. Strong contracts that empower plan sponsors to hold PBMs accountable, conduct annual market checks and reconcile rates and rebates are no longer optional—they’re essential. Pharmacy benefit strategies shouldn’t sit on the shelf and only be revisited every three to five years. When it’s time for a PBM RFP, it must be approached strategically, backed by expert analytics, clinical insight and a comprehensive evaluation of PBM options.
Despite the clear need for these actions, many plan sponsors are still leaving value on the table. The 2025 Pulse of the Purchaser survey found that only 50% of respondents had clearly defined rebate terms in their contracts, and just 67% reported having audit rights. While audit rights have become more common, employers shouldn’t have to rely solely on audits to unlock the full value of their PBM agreements.
Prediction #3: Savings in pharmacy benefits take both short- and long-term strategies focused on trend management.
TRUE: While quick savings from a PBM RFP or vendor switch are possible, long-term impact comes from managing the trend rather than simply resetting it. During our 2025 webinar, we emphasized that the real value in pharmacy benefits comes after the contract is signed. Employers that actively manage their PBM relationships, hold vendors accountable and continually uncover opportunities are the ones who truly bend the cost trend over time.
Trend management isn’t a one-time event; it’s a year-round discipline. It starts with ongoing pharmacy and trend reviews, followed by financial reconciliation in Q2, market checks in Q3 and contract updates in Q4. Each step builds on the last, creating a cycle of continuous improvement that supports both short- and long-term savings.
We’re also seeing a shift toward unbundling pharmacy services—such as separating rebates, formularies and specialty management—to gain more control and transparency. Among our clients with over 2,500 members, 48.6% have already carved out at least one component of their pharmacy benefits. Yet, broader adoption remains limited; a 2025 employer survey found that only 21% are very likely and another 12% moderately likely to consider unbundling in the near future.
Prediction #4: Savings opportunities are available to plan sponsors who make the decisions to leverage them.
TRUE: On a surprising note, our prediction about Stelara biosimilars (ustekinumab) delivering measurable savings is happening sooner than we expected. We anticipated these biosimilars would gain market share faster than their Humira counterparts, but PBMs moved even faster than expected. From launching with aggressive pricing to making formulary shifts within the first six months, many plan sponsors are now capturing savings at a much quicker pace than originally forecast.
Still, the opportunity isn’t being fully realized. Many PBMs have yet to adopt a comprehensive biosimilar strategy, resulting in continued reliance on brand-name drugs and rising costs for related therapies. A more proactive, true biosimilar-first strategy approach could unlock deeper savings and stronger long-term value.
Prediction #5: Plan sponsors cannot wait on legislation for savings as federal legislation will continue to be slow while state legislation will continue to hit barriers.
TRUE: The year 2025 saw a wave of legislative activity at both the federal and state levels, with executive orders playing a more prominent role than in previous years. While most federal PBM reform efforts failed to materialize—most notably, all PBM-related provisions were stripped from the final version of the One Big Beautiful Bill Act—Executive Orders have delivered a mix of outcomes and confusion. For example, directives around Most Favored Nation (MFN) pricing have fueled the growth of direct-to-consumer drug pricing platforms. These sites promise savings, but their true impact on employer-sponsored plans remains unclear. Meanwhile, Executive Orders affecting tariffs continue to influence drug pricing and global supply chain dynamics.
At the state level, legislative momentum has been even stronger. Notable developments in 2025 include Arkansas House Bill 1150, which prohibits PBMs from owning or holding financial interests in pharmacies, and Iowa Senate Bill 383, which mandates rebate pass-through, NADAC-based pricing and standardized pharmacy dispensing fees. However, these laws are not without challenges. Legal questions around Commerce Clause discrimination and ERISA preemption are already surfacing, potentially delaying or reshaping implementation.
In addition to legal challenges, state legislative efforts are also producing unintended consequences. Illinois House Bill 1697 introduced a $15 per-member annual fee on PBMs to support independent pharmacies. However, the fee is not coming out of PBM profits—in many cases, the cost is being passed directly to plan sponsors.
Many of the predictions we shared earlier in 2025 were delivered—from rising fiduciary scrutiny and accelerated biosimilar adoption to bold state-level legislation and evolving PBM strategies. While federal reform lagged, employers who implemented proactive contract management, trend oversight and strategic carve-outs saw meaningful progress.
As we look ahead to another transformative year, join us for our 2026 Predictions for Pharmacy Benefits webinar to stay informed, prepared and ahead of the curve.
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Behind the Curtain: 2026 Predictions for Pharmacy Benefits
January 20, 2026
12:00 – 1:00 PM (EST)