As the year winds down, the pharmacy benefits market continues to experience rising costs. With pharmacy benefits now accounting for 25% of total healthcare spending and employer drug costs expected to rise 12% this year alone, self-funded employers and labor unions are bracing for renewal numbers that they are concerned about absorbing.
The instinct in moments like this is to consider switching your pharmacy benefits manager (PBM), or even the benefits advisor, to find a better deal. But according to the 2026 State of Pharmacy Benefits Decision report, fielded by FTI Consulting on behalf of RxBenefits, that instinct may be leading employers into a trap.
Three out of four employers have changed their advisor in the past 12 months or expect to within the next 12 months. The PBM churn is even higher, with 87% of employers saying they are likely to consider switching providers at renewal. The problem isn’t the vendor – but it might be what the vendor is doing – or perhaps not doing.
Here’s what most headlines miss: drug prices aren’t the main driver of plan cost increases right now. Utilization is. More members are filling more high-cost prescriptions, and many of those claims aren’t getting the scrutiny they deserve. Swapping PBMs doesn’t fix that, but independent clinical management does.
The Real Cost Driver Hiding in Your Claims
Utilization has two key parts: how many prescriptions your members fill and which drugs they’re taking. More prescriptions aren’t always the issue. A member who manages blood pressure with a low-cost generic protects the plan from far more expensive medical claims later.
The trouble starts when high-cost drugs replace lower-cost options that work just as well, or when prescriptions slip through without a real review. The market data shows how quickly that adds up:
- Specialty drugs make up about 2% of prescription volume but more than half of pharmacy spending, according to RxBenefits book of business data.
- Net drug spending in the U.S. hit $606 billion in 2025, up 10.6% year over year, according to IQVIA. And, net prices are expected to grow another 4.5% to 7.5% through 2030.
- GLP-1 spending rose more than 500% from 2018 to 2023, from $13.7 billion to $71.7 billion, according to the American Medical Association (AMA) and the Centers for Disease Control and Prevention (CDC). Adults specifically taking GLP-1s for weight loss rose to 11% in 2026, up from 8% in 2025.
A small number of claims drives most of a plan’s cost. That’s why every high-cost approval matters, and why active clinical management is the most important lever to reliably bend trend.
When the System Gets Gamed
Some of the pressure comes from members looking for a path to coverage. At independent pharmacies, some patients are asking which diagnosis codes will qualify a drug for coverage. For example, a member hoping to use a GLP-1 for weight loss may ask about a diabetes code that would meet the plan’s prior authorization (PA) criteria.
These requests often come from real frustration with cost and access. Still, they put pharmacists in a difficult position. They can also lead to claims that the plan wasn’t designed to cover. Automated approval systems check whether a code matches the coverage criteria. They aren’t built to confirm whether the patient’s chart supports that diagnosis.
The solution is clear, though it takes deliberate effort. A human-led review of the chart notes can confirm that the prescription is medically necessary. That kind of review can catch details that code-matching software may miss. Data from the 2026 RxBenefits report points in the same direction: 92% of employers and 94% of advisors rated patient and provider outreach to encourage lower-cost alternatives as a very or somewhat effective utilization management tool. For a growing number of plans, independent clinical oversight is now a core part of managing GLP-1 spend while keeping members’ needs in view.
Why Your PBM Shouldn’t Review Its Own Claims
Your PBM negotiates rebates, builds the formulary, and often owns the pharmacy that fills the prescription. In many plans, that same PBM decides whether the prescription gets approved.
That’s a potential conflict of interest. When a PBM profits from rebates, spread pricing, and dispensing fees, it may have little incentive to say no to a high-cost claim. Plan sponsors are catching on. In Pharmaceutical Strategies Group’s 2026 Trends in Specialty Drug Benefits Report, few payers said a model where the PBM owns the specialty pharmacy and manages utilization is fully in their best interest. Many said they’d accept fewer rebates in exchange for stronger utilization controls.
You wouldn’t let a contractor inspect their own work. And the PA process deserves the same independence.
Act Before Renewal Season Locks You In
Cost pressure won’t ease on its own. New specialty drugs keep coming, with 50 to 55 new medicines expected to launch annually over the next five years. GLP-1 demand and use keeps climbing, and every unreviewed approval adds to next year’s costs. Waiting means another year of paying claims that the plan shouldn’t cover, which doesn’t solve the core problem.
Look for a partner that handles PAs independently, with the only goal to get members the right drug at the right price. Here’s what that looks like in practice:
- Real chart note reviews. Clinical pharmacists examine the medical record, not just the diagnosis code, to confirm medical necessity.
- Off-label oversight. Prescriptions for use outside FDA-approved indications get flagged before your plan pays.
- Prescriber outreach. When a lower-cost drug works just as well, pharmacists engage the prescriber directly about alternatives.
- GLP-1 program management. Structured controls keep coverage appropriate and utilization in check.
- Member protection. Every review weighs safety alongside cost, so members get care that fits their condition.
This is active management. Not a model claim, not a label, but measurable intervention delivered as trend develops, not after the money’s gone.
