PBM 101, Part 2: Choosing the Right PBM in a Time of Rising Costs and Changing Rules
Drug costs continue to surge, regulatory winds are shifting, and employers are bracing for steeper expenses ahead. Now more than ever, your choice of PBM partner can be a major differentiator or a liability.
Why This Moment Matters
Cost growth expectations are steep. Employers are forecasting higher health care costs in 2026, with pharmacy spend as a central contributor. Some projections suggest pharmacy alone may rise by double digits next year, far outpacing general medical cost trends.
Reform pressure is building. PBM practices are under increasing scrutiny. Policymakers, physician groups, and pharmacy organizations are pushing for reforms that would delink PBM profits from drug list prices, increase transparency, and ensure savings flow to plan sponsors and patients. PBMs themselves are already floating proposals to adjust their practices ahead of possible legislation.
Regulation is becoming inconsistent and complex. While federal courts and Congress weigh in, states continue to pass new PBM laws. For multi-state employers, this means navigating a patchwork of rules that can be confusing, sometimes conflicting, and potentially at odds with fiduciary obligations.
What to Look for in a PBM Partner
Given this evolving landscape, employers should place extra emphasis on:
- Regulatory agility and compliance support
Your PBM must help you navigate both federal and state-level requirements, protecting your plan against compliance risk. - True cost transparency and incentive alignment
Demand clarity on how your PBM is compensated. Incentives should be aligned with your plan, not tied to higher drug list prices or opaque rebate arrangements. - Formulary integrity and clinical governance
With expensive therapies hitting the market, your PBM should balance cost savings with clinical appropriateness, ensuring members receive the right drug, not just the cheapest option. - Benefit design flexibility
Rising costs require innovative plan designs such as specialty carve-outs, differential cost-sharing, or utilization management. Your PBM should be a partner in shaping these strategies, not a barrier. - Member experience and adoption tools
With members facing higher cost-sharing and more complex therapies, digital tools, adherence programs, and proactive engagement are essential for better outcomes. - Proven performance and benchmarking
In this climate, results matter. Your PBM should demonstrate measurable cost savings and clinical outcomes year over year, benchmarked against peers.
The Bottom Line
Plan sponsors are entering a pivotal moment. The forces shaping pharmacy benefits include cost escalation, regulatory change, and clinical complexity. The status quo will not be enough.
Choosing a PBM partner with regulatory foresight, aligned incentives, clinical integrity, and member-centric tools can help employers navigate this era, mitigate risk, and deliver sustainable value to their workforce.
Sources
- Reuters – Pharma middlemen propose regulatory changes to avoid Trump administration rules
- Pharmacy Times – Pharmacy policy updates for September 2025
- Bloomberg Law – Drug benefit compliance is a state-by-state test for sponsors
- NASPA – Over 100 pharmacy organizations urge PBM reform
- AMA – Advocacy update spotlight on PBMs
- Healthcare Dive – Employers expect 9% higher health costs in 2026
- WorldatWork – Business Group on Health predicts 9% higher healthcare costs in 2026
- PwC – Behind the numbers: Rising drug spend
- ProCare Rx PBM 101 video script
About ProCare Rx
ProCare Rx is a privately held, independent pharmacy benefit manager (PBM) that has empowered healthcare and self-insured organizations since 1988. We provide fully integrated, in-house solutions—including claims adjudication, clinical program design, pharmacy network access, cost containment, and data analytics—all supported in the U.S. Our flexible, transparent model serves self-insured employers, third-party administrators (TPA), brokers, health plans, health systems, managed care organizations (MCO), unions, workers’ compensation programs, Medicare, Medicaid, hospices, and other PBMs. With a proprietary technology platform, commitment to ethical operations, and a focus on lowest net cost, ProCare Rx delivers long-term value, clinical performance, and trusted pharmacy benefit partnerships.
Media Contact:
Marc Cohen, VP, Marketing and Sales
marketing@ProCareRx.com
