The Pharmacy Benefits Playbook is Being Rewritten—Here’s Your Executive Summary
The pharmacy benefits landscape is transforming faster than at any point in the past two decades. For plan sponsors, this creates both risk and opportunity. Those who understand and prepare for emerging trends will achieve better outcomes; those who don’t will fall behind.
Here’s your executive overview of the five forces reshaping pharmacy benefits through 2030.
The Current Challenge
Plan sponsors face two realities: pharmacy costs continue rising, and transparency remains elusive. The traditional playbook, delegate everything to a PBM and hope for the best, is no longer sufficient.
The good news? Change creates opportunity for organizations willing to act proactively.
Five Forces Reshaping the Landscape
1. PBM Pressure: PBM Models Change the Landscape
The trend: The one-stop-shop PBM model has been breaking down but has the potential to rebuild as PBMs change their approach. Where plan sponsors needed to disaggregate their offerings for the best savings, changing in PBM models may allow for the realignment of some PBM incentives.
What’s changing:
- PBMs have transitioned from spread pricing to transparent models and are now adding on new pricing models (cost-plus, NADAC-based, drug-level guarantees)
- Rebate models are evolving with more point-of-sale benefits and announcements of PBM models with rebates incorporated in pricing
- Plan sponsors are reclaiming oversight of formulary, clinical strategy, and specialty management
Timeline: Expect new models to be the mainstay by 2028-2029.
Bottom line: PBMs are responding to pressure in the market plan. Successful organizations will maintain appropriate oversight and require PBMs that are nimble and responsive to the market.
2. Direct from Manufacturer: Bypassing the Middleman
The trend: Pharmaceutical manufacturers are increasingly going direct to consumers and plan sponsors, bypassing traditional PBM channels.
What’s happening:
- DTC websites offering cash prices 50-70% below insurance prices
- Plan sponsors have limited access to these prices and added complexity
- New vendors helping plan sponsors access manufacturer direct pricing
Looking to the future, manufacturers may respond with pricing models that are not reliant on rebates.
Timeline: DTC options are available now and expanding rapidly. Direct plan sponsor programs will become mainstream by 2028-2029.
Bottom line: As direct pricing grows, traditional rebate models matter less, changing PBM value propositions fundamentally.
3. GLP-1 Management: The Continued Spend Tsunami
The trend: GLP-1 medications (Ozempic, Wegovy, Mounjaro, Zepbound) are positioned to become the top pharmacy spend category, potentially exceeding specialty drugs.
Why it matters:
- Massive patient populations (100+ million Americans have qualifying conditions)
- High costs ($12,000-$16,000+ annually per patient)
- Long-term or lifelong use
- Expanding indications and new agents launching throughout 2026-2027
Timeline: GLP-1s will be the top spend category for most plan sponsors by 2027-2028.
Bottom line: This isn’t a question of whether GLP-1s will impact your budget, but whether you’ll manage that impact proactively or reactively. Organizations implementing strong clinical criteria, outcomes-based approaches, and alternative access models will fare best.
4. Biosimilar Management: The Multi-Billion Dollar Opportunity
The trend: Blockbuster biologics totaling tens of billions in spend are losing exclusivity, but savings require proactive biosimilar strategies.
The opportunity:
- True biosimilar-first strategies can deliver 40-60%+ savings
- Dozens of blockbuster drugs lose exclusivity between now and 2037
- Early movers capture savings; late adopters leave money on the table
The challenge:
- PBM misaligned incentives (rebate aggregator ownership) slow adoption
- Different strategies deliver dramatically different results
- Both pharmacy and medical benefits are impacted
Timeline: Organizations implementing true biosimilar-first strategies will achieve maximum savings in 2026. PBMs will be slower to move without client pressure.
Bottom line: Don’t wait for your PBM to drive biosimilar adoption. The savings opportunity is too large to ignore.
5. Legislative Pressure: Don’t Count on Congress
The trend: Despite significant federal and state legislative activity around PBMs and drug pricing, meaningful relief will be limited and slow.
The reality:
- Most-Favored-Nation pricing will have minimal impact on plan sponsors
- Federal PBM reform will eventually drive some change, but slowly
- State PBM regulations will create complexity more than savings
- Real change is coming from market forces, not legislation
Timeline: Even optimistically, meaningful federal reform won’t impact plan sponsors until 2028-2030. State reform is creating complexity now.
Bottom line: Build your strategy assuming limited legislative help. Organizations waiting for Congress to solve their pharmacy benefit challenges will fall behind.
The Common Thread: Take Proactive Control
Across all five trends, one message emerges: the organizations that will succeed are those that take proactive ownership of their pharmacy benefits.
This means:
- Maintaining oversight regardless of PBM arrangement
- Implementing strong clinical strategies
- Strategically disaggregating where it creates value
- Exploring innovative pricing models and vendor solutions
- Not waiting for legislative rescue
Three Action Steps for 2026
- Audit Your Current State
- What’s your PBM actually doing and at what cost?
- Where are your biggest cost drivers?
- What did your last annual reconciliation and market check show you?
- Develop Your Strategic Plan
- Which services should remain with your PBM vs. carved out?
- What clinical strategies are needed for GLP-1s, biosimilars, specialty drugs?
- How will you access emerging pricing models?
- Don’t Go It Alone
- Partner with experts who can help navigate this complexity
- Connect with peers managing these challenges
- Stay informed as the landscape continues evolving
The Future is Coming Fast
The pharmacy benefits landscape of 2030 will be dramatically different from today:
- PBM relationships will be more transparent and targeted
- Direct manufacturer relationships will be common
- GLP-1 management will be sophisticated and outcomes-based
- Biosimilar-first approaches will be standard practice
- Clinical strategy will be as important as vendor selection
The only question: will your organization be leading this transformation or scrambling to catch up?
Want to discuss how these trends impact your specific situation? Contact our pharmacy benefits experts to schedule a consultation and develop a strategy tailored to your organization’s needs.