1. Move from Rebate Optimization to Total Cost of Care Accountability

For years, PBM economics centered around rebate aggregation. That model is under intense scrutiny at both the federal and state level.

By 2026, leading PBMs must:

• Align contracts to net cost transparency
• Tie guarantees to total cost of care (TCOC), not just drug spend
• Demonstrate measurable impact on:
  • Inpatient admissions
  • ER utilization
  • Medication adherence
  • Risk adjustment accuracy
  • CMS Star performance

Health plans are demanding:

“Show me how pharmacy lowers my medical loss ratio.”

PBMs must evolve into clinical and financial risk partners, not rebate brokers.

2. Integrate Pharmacy with Risk Adjustment and Quality Programs

Pharmacy data is the most underutilized strategic asset in Medicare Advantage, Medicaid, and ACA markets.

PBMs in 2026 must:

• Integrate pharmacy data into risk adjustment suspecting models
• Align with CMS-HCC documentation strategies
• Support care gap closure through medication adherence analytics
• Proactively impact:
  • Stars adherence measures (PDC)
  • Diabetes, statin, and RASA metrics
  • CAHPS medication access experience

This is especially critical under programs such as the Centers for Medicare & Medicaid Services Star Ratings model, where pharmacy performance directly drives bonus revenue.

If a PBM cannot quantify how it improves RAF accuracy and Star revenue, it is leaving value on the table for its health plan clients.

3. Redesign the Specialty and GLP-1 Strategy (Not Just Manage It)

Specialty drugs and GLP-1 therapies are redefining pharmacy economics.

PBMs must:

• Build outcomes-based contracting models
• Develop evidence-based GLP-1 continuation criteria
• Support employer and plan-level policy customization
• Integrate nutrition and behavioral health support for obesity therapies
• Manage pipeline drugs (gene therapies, oncology biologics) with actuarial foresight

The rise of GLP-1 therapies like Ozempic and Wegovy has exposed weaknesses in utilization management, long-term outcomes modeling, and benefit design flexibility.

2026 PBMs must shift from:

• “How do we control volume?”
  To:
• “How do we optimize outcomes and affordability?”

4. Deliver Radical Transparency and Regulatory Readiness

The regulatory environment is tightening.

With oversight from agencies like the Federal Trade Commission and increasing state-level PBM legislation, opacity is no longer a viable strategy.

Health plans need PBMs that:

• Provide transparent pass-through pricing options
• Offer clear spread reporting
• Prepare for Medicaid managed care and Medicare audit scrutiny
• Align contracts to value-based purchasing models
• Proactively support compliance documentation

PBMs must become compliance-forward organizations — helping health plans withstand audit, RADV reviews, and rate negotiations.

In 2026, transparency will be a competitive differentiator.

5. Reimagine the Member Experience

Pharmacy is often the most frequent touchpoint a member has with the healthcare system.

Yet frustration persists:

• Prior authorization delays
• Confusing formularies
• High out-of-pocket costs
• Fragmented specialty delivery

Innovative PBMs must:

• Simplify digital prior authorization workflows
• Use AI-driven medication navigation tools
• Provide real-time cost transparency at prescribing
• Support home delivery with human navigation support
• Integrate pharmacists into virtual care models

The best PBMs will evolve into member advocacy platforms, not transactional processors.

Patient experience is no longer a “nice to have.”
It directly impacts retention, CAHPS scores, and employer satisfaction.