Pharmacy benefit management (PBM) has long operated in the shadows. For decades, few leaders had visibility into the terms, fees, or incentives that drive prescription costs. That era is ending. Prescription drug spending jumped 10.2% in 2024 to nearly $806 billion, and 2025 brings sweeping reforms under the Big Beautiful Bill. The law bans spread pricing in Medicaid, restricts PBM compensation to administrative fees, and mandates pass-through reimbursement with greater transparency. For health plans and employers, adapting to this new reality isn’t optional — it’s a competitive necessity.

Four Forces Reshaping the PBM Landscape

  1. The rise of transparent, technology-powered PBM models
  2. The rapid growth of GLP-1 therapies and expanded indications
  3. The disruptive potential of biosimilars
  4. The financial balancing act of gene therapies

Transparency as the New Contract Mandate

Today, transparency demands proof. Contracts must go beyond promises to clearly state net costs while eliminating hidden spreads and rebate games. But a contract alone isn’t enough. Technology now enables near-real-time, claim-level visibility, giving employers and health plans insight into adjudication, price integrity, and network performance before they affect members.

Enforceable audit rights and automated triggers are becoming standard. This combination of data, accountability, and contractual rigor is building PBM partnerships grounded in verifiable results.

GLP-1 Therapies and the Coming Wave

Demand for GLP-1s is surging, and with new indications on the horizon, the financial stakes are rising fast. The sustainable path forward lies in outcomes-based management: data-driven eligibility, conditional coverage tied to clinical progress, and member coaching to support adherence.

Budget guardrails, such as stop-loss coverage and predictive utilization modeling, are essential to balance access with affordability and protect plan design from runaway costs.

Biosimilars: Adoption by Design

Specialty drugs remain the steepest part of the cost curve. Biosimilars offer clinically equivalent, lower-cost alternatives, but adoption doesn’t happen automatically. Plans must make biosimilars the default first-line option, reserve reference brands for documented medical necessity, and align reimbursement to avoid perverse incentives.

Speed matters. Rapid prior authorization, real-time reporting, and weekly adoption tracking by prescriber and site of care help eliminate bottlenecks. The ustekinumab drug class (Stelara and its biosimilars) represents a key test case. Plans that act decisively will capture significant savings; those clinging to rebate-driven models risk losing millions.

Gene Therapies and the High-Stakes Equation

A single infusion can transform a life, but its multimillion-dollar upfront cost doesn’t fit traditional one-year budget cycles. Gene therapies should be treated as long-term health investments, not short-term expenses. Employers and PBMs are experimenting with annuity-style payments, outcome-based contracts, and performance warranties tied to clinical milestones.

The ability to deliver these breakthroughs depends on operational readiness — centers of excellence, pre-negotiated agreements, and financing models that balance patient access with fiscal sustainability.

The Path Forward

Transparency, performance, and foresight are no longer optional — they form the foundation of modern pharmacy benefit strategy. Success now depends on ironclad net-cost contracts backed by daily data, GLP-1 coverage conditioned on outcomes, biosimilars as the default standard, and gene therapies financed as long-term investments.

The good news: none of this requires heroics. It requires discipline, visibility, and the will to solve small problems before they become large ones. For those who act decisively, this moment represents more than a challenge — it’s an opportunity to reset the rules of pharmacy benefits for employers, patients, and the healthcare system as a whole.