For decades, employers and health plans (Payers) have relied on benefit consultants and Pharmacy Benefit Managers (PBMs) to help them navigate one of the most complex and expensive components of healthcare: pharmacy benefits. These partners are entrusted with managing billions of dollars, influencing clinical decisions, and shaping member access to medications. Yet too often, employers and Payers are asked to operate on trust alone, without the transparency, data, or alignment necessary to truly act as fiduciaries.
It’s time to reset expectations. Employers and payers deserve better.
Transparency Is Not Optional
True transparency is foundational to good decision‑making for both employers and health plans. Yet many organizations, particularly self‑insured employers and payers, struggle to access complete, usable pharmacy claims data. Drug spend is increasingly siphoned through opaque, vertically integrated channels, making it difficult to understand where dollars are actually going and who is retaining value along the way. When data is made available, it is often incomplete, difficult to interpret, or missing critical context. Rebate information is rarely available at the claim level, and revenue retained by PBMs, GPOs, or PBM‑owned pharmacies is frequently obscured.
Without a clear view of the true cost of a drug, neither employers nor payers can evaluate whether a recommended formulary, network, or utilization strategy is the most cost‑effective option. Transparency is not about flooding stakeholders with reports, it’s about delivering complete, actionable insight that enables informed choices.
A Shared Reality for Employers and Payers
Employers and payers now face the same structural challenge: pharmacy cost growth has become the primary driver of total medical trend. Specialty drugs, biologics, and novel therapies are clinically transformative but financially destabilizing, placing pressure on fully insured premiums, self‑funded plan budgets, and risk‑bearing arrangements alike.
However, what is rapidly changing is the regulatory and enforcement backdrop governing pharmacy benefit management. Federal policymakers have made it clear that PBM practices are no longer treated as private contracting matters, but as issues of competition, consumer protection, and fiduciary responsibility.
Several forces are reshaping the pharmacy landscape for both employers and payers:
- Specialty drugs dominate spend. Specialty medications represent the majority of net drug spending while being used by a very small percentage of members. Oncology, anti-inflammatory medications, rare disease therapies, and cell and gene therapies routinely carry six‑ and seven‑figure annual price tags.
- Growth is concentrated and persistent. Oncology and obesity‑related GLP‑1 therapies are projected to be the largest contributors to pharmacy cost growth over the next several years. While biosimilars are expected to slow growth in some categories, savings are often diluted by utilization growth and rebate‑driven formulary behavior.
- Payment channels are fragmented. The divide between medical and pharmacy‑benefit drugs creates inconsistent pricing, variable site‑of‑care costs, and misaligned incentives. Physician‑administered drugs, hospital outpatient infusions, and PBM‑controlled specialty pharmacies operate under different rules, making holistic cost management difficult.
- PBM revenue models are under pressure. Federal action from FTC enforcement, Department of Labor rulemaking, and the Consolidated Appropriations Act of 2026 signal that traditional PBM economics built on opaque fees, affiliate revenue, and rebate retention are no longer acceptable. As these models are constrained, PBMs are expected to seek new revenue streams, reclassify fees, and redefine services, in order to protect their profits.
- Operational barriers slow adoption of alternatives. Although awareness of PBM unbundling and alternative models is growing, both employers and payers cite similar barriers: vendor coordination, data integration, member disruption concerns, and uncertainty about realized savings.
The result is a shared burden: employers and payers are absorbing escalating pharmacy risk at the same time regulators are explicitly placing them “in the driver’s seat” as fiduciaries responsible not just for outcomes, but for oversight, verification, and action.
Consultants Must Be Conflict‑Free
Benefit consultants play a pivotal role for both employers and payers, shaping strategy, vendor selection, and ongoing oversight. That role demands independence. Consultants should be expected to sign and stand behind conflict‑free statements, demonstrating that their compensation comes solely from their clients and not from PBMs, vendors, or downstream arrangements.
Fee structures matter. When consultants are incentivized by activity like audits, RFPs, or vendor churn rather than outcomes, the fiduciary obligation to employers and payers is compromised. Advisors should be aligned to results, not volume.
RFPs Should Measure What Actually Matters
When a PBM RFP is warranted, the focus must extend far beyond rebate and network guarantees. Guarantees without context, particularly when no true price ceiling exists, offer little protection in an environment where total pharmacy spend continues to rise.
Employers and payers should evaluate PBMs on:
- Their ability to manage total cost, not just negotiate deeper discounts and rebates.
- Clinical strategy for high‑impact categories such as oncology, immunology, GLP‑1s, MS, and rare disease.
- Transparency into rebate, fee, and specialty pharmacy economics.
- Flexibility to support carve‑outs, modular services, and evolving site‑of‑care strategies.
Clinical management is not an administrative function, it is a primary cost and quality lever.
Network Strategy Impacts Access, Cost, and Communities
Network design is both a financial and healthcare infrastructure decision. Exclusive specialty and mail‑order mandates may simplify administration, but they often eliminate price competition and lock employers and payers into vertically integrated channels with limited accountability.
Employers and health plans should expect fair‑market reimbursement for pharmacies, transparency in how network pricing is established, and the flexibility to include alternative pharmacies when they deliver better value. Local pharmacies and independent specialty providers remain essential to patient access and cost containment.
Programs Are Not Created Equal
Copay assistance, patient assistance, biosimilar strategies, and cost‑management programs can deliver real value, but only when designed and administered effectively. In high‑growth categories like GLP‑1s and oncology, poorly structured programs may shift costs rather than reduce them, masking trend while increasing long‑term exposure.
Employers and payers must understand not just whether a program exists, but how it operates, how performance is measured, and how it aligns with broader clinical and financial goals.
What This Means Right Now
Federal reform has moved pharmacy oversight from theory to obligation. For employers and payers acting as fiduciaries, three actions matter immediately:
- Inventory who is truly acting as a PBM. Do not rely on vendor labels. Identify every entity that touches formulary design, drug pricing, rebates, pharmacy reimbursement, or utilization management, including affiliates, rebate aggregators, and specialty partners, and treat them as fiduciaries subject to disclosure and audit expectations.
- Validate transparency, not promises. Review existing PBM and pharmacy‑related contracts to confirm that all forms of compensation including rebates, fees, alternative discounts, and affiliate revenue, are fully disclosed and auditable. If transparency depends on trust rather than verification, the fiduciary risk sits with the employer or payer.
- Prepare for PBM behavior shifts. As legacy rebate‑driven models are constrained, expect PBMs to introduce new fees, redefine services, or shift economics toward specialty drugs and affiliated channels. Fiduciaries should proactively model these scenarios and establish guardrails before cost and complexity are passed downstream.
Strategy for Today…and Tomorrow
Managing pharmacy benefits is no longer just about controlling today’s costs. It is about preparing for a future defined by precision medicine, gene therapies, expanding indications, and sustained specialty growth.
Employers and payers need partners who provide foresight, data‑driven insight, and the flexibility to move beyond legacy PBM models. If consultants and PBMs cannot help their clients manage pharmacy benefits while improving care and removing waste, it is fair to ask: what purpose do those partnerships serve?
A Higher Standard
Employers and payers deserve advisors they can trust to deliver unbiased, clinically sound, and cost‑effective recommendations. They deserve PBMs and partners that act in their best interest. Without these pillars, organizations are left carrying escalating pharmacy risk without adequate control.
At MacroHealth, we believe this higher standard should apply to both employers and payers. It should be the norm, not the exception. Employers and payers deserve better, and the industry must rise to meet that expectation.