2026 Forecast: The Year of PBM Clarity 

This is shaping up to be a pivotal year in health care, especially in pharmacy benefit management (PBM). With rising costs, policy reform on a national scale and growing pressure from plan sponsors and members, one theme stands out: clarity.

Will 2026 be the year that PBM transparency becomes the expectation instead of the exception?  

Reform Is Happening Now and Moving Faster 

It’s no secret that legislators and regulators are sharpening their focus on drug pricing and rebate structures. Huge companies are being put under a microscope, and those findings are being used to redraft the rules of the PBM industry. In the coming months, plan sponsors can expect to see some big changes around traditionally opaque business practices, reporting and specialty drug pricing.  

As a response to these continuing issues, more than 23 states have already enacted drug transparency laws. On top of that, 12 states have created prescription drug affordability boards to review the costs of specific prescription drugs.¹ While Navitus has always offered 100% transparency and pursued the lowest net cost for our partners, many other PBMs are feeling pressure to change the way they do business after decades of keeping their numbers behind closed doors. 

Meanwhile, at the federal level, new U.S. Department of Health and Human Services rules that took effect on October 1, 2025, now require real-time access to prescription drug pricing and coverage information, while streamlining prior authorization processes.² More and more, we’re seeing that the country is demanding increased transparency in PBM business practices, and legislators are working to pass laws to make it happen. 

Transparency is Becoming the Expectation 

At Navitus, we’ve cited our dedication to clarity of drug costs for over 20 years, and it’s ingrained as a pillar of our business practices. A small number of other PBMs have seen the way the wind is blowing and started touting their “transparency” as well. But many are finding out the hard way that transparency and auditability are no longer optional features. They’re what’s expected of PBMs at every level of business.  

According to Healthcare Finance News, between 2024 and 2025, the use of alternative PBMs, those viewed as more transparent, increased from 12% to 31%. During this same period, reliance on the big three PBMs fell from 72% to 61%.³ It seems that now more than ever, people really want a PBM they find trustworthy, so they can truly know where their money is going.  

Specialty Drug Prices Are Out of Control  

There have also been many discussions at the national level around achieving greater accountability in pricing for specialty medications, which are high-cost drugs that often come with complex needs. Due to ongoing opaque practices, the cost of a single specialty medication can vary by tens of thousands of dollars.  

In fact, according to a report from the Federal Trade Commission, a variety of specialty generic drugs dispensed by pharmacies affiliated with the big three PBMs were marked up by hundreds and even thousands of percentage points. These huge price increases filled those PBMs’ coffers with more than $7.3 billion in revenue.⁴ That’s money taken directly out of the pockets of employers and health plans. And it’s so widespread that only a higher level of transparency and auditability can rein in these massive discrepancies in specialty drug spending. 

If this past year has shown traditionally opaque PBMs anything, it’s that clarity isn’t a luxury, it’s a leadership decision. And 2026 offers a simple choice: lead with clarity or see how long your opaque PBM can stay in business. 

see how our decades of dedication to clarity can improve your benefit plan

Reach out to [email protected]. 

References

1. Ingram HR, Wetzel M, Strauss A. State drug transparency laws: 2025 update. Goodwin. Published June 2, 2025. Accessed October 23, 2025. www.goodwinlaw.com/en/insights/publications/2025/06/alerts-lifesciences-state-drug-transparency-laws

2. U.S. Department of Health and Human Services. Americans to gain new access to real-time prescription drug price information. Published September 2, 2025. Accessed October 23, 2025. https://www.hhs.gov/press-room/hhs-prescription-drug-price-transparency-rule.html 

3. Lagasse J. Employers increasingly eyeing more transparent PBMs. Healthcare Finance. Published September 15, 2025. Accessed November 26, 2025. www.healthcarefinancenews.com/news/employers-increasingly-eyeing-more-transparent-pbms

4. FTC. FTC Releases Second Interim Staff Report on Prescription Drug Middlemen. Published January 14, 2025. Accessed November 26, 2025. www.ftc.gov/news-events/news/press-releases/2025/01/ftc-releases-second-interim-staff-report-prescription-drug-middlemen