Pharmacy Benefits Shakeup: 2026 Trends and Predictions

The pharmacy benefits landscape is undergoing a massive transformation, driven by a demand for transparency, affordability, and clinical value from businesses, providers, and patients alike. As we look ahead to 2026, the movement toward modern, clear pharmacy benefit manager (PBM) models is accelerating, fueled by employers who are tired of waiting for legislation or action by legacy players to fix a broken system. 

The next year is going to be chock-full of changes for pharmacy benefits: from new medication advances that will lead to lower prices to fundamental changes to the ways pharmacy benefits are structured. 

Let’s explore the top trends we at SmithRx see shaping pharmacy benefits in 2026. 

Business Decisions Are Outpacing PBM Reform

One thing is for certain: businesses are not waiting for government reform when it comes to taking control of their pharmacy benefits. 2026 is poised to be the year of the modern pharmacy benefit manager. An unprecedented number of businesses are set to launch with, or adopt, modern, transparent PBM alternatives in the coming year. 

While state-level PBM legislation has shown progress in states like California, Iowa, and Arkansas, federal lawmakers have been slower to act, leaving industry giants to “self-regulate”. This leaves the door open for legacy PBMs to offer lip service policy changes and business restructurings, but these “new” models lack substance and maintain the same, misaligned incentives.

In response, HR and benefits leaders are seizing control of their pharmacy spend. More and more decision makers are seeing through the legacy PBM rhetoric and are seeking out partners who can offer cost control and greater financial visibility. Countless large-scale businesses, including new SmithRx client, UnitedAg, have made the leap to modern pharmacy benefit managers. This groundswell of movement confirms that the market is moving, and modern, transparent PBMs are becoming industry standard for businesses of all sizes, regardless of what Capitol Hill does or does not legislate. 

Legacy PBMs Will Disguise Bad Action with Reform Lip Service

As public and legislative pressure mounts, more legacy PBMs will announce their “new and improved” models. Though these reforms and transformations sound great on paper (we’ll continue to see “transparency” and “pass-through” misused), they’re unlikely to result in meaningful changes for the Big 3’s bad actions, or result in better financial outcomes for businesses and members.

These entities will still maintain the incentive to take spread from medication pricing or introduce new, disguised fees to retain pharmaceutical revenue, fundamentally keeping them misaligned with their clients. Just as legacy players glommed onto buzzwords like transparency and pass-through, but still continued to deliver rising costs to their clients, these new PBM claims won’t result in impactful change. 

More than ever before, 2026 is the year for employers to not take their PBM’s word that they’re transparent and aligned—they need to prove it.

Employers Will Carve-Out GLP-1s for Weight Management

Though they’ve dominated pop culture headlines for the past few years, GLP-1s are becoming a hotter topic in the world of benefits as their interest, demand, and list of potential indications continue to expand (being studied in heart failure, kidney disease, fertility (e.g., PCOS), addiction, chronic pain, Alzheimer's, and Parkinson's). These medications are not likely to fade from the public consciousness any time soon with a potential new, oral version of Wegovy slated to be reviewed by the FDA by 2025 or early 2026. These advances will almost certainly be followed by patient interest demand spikes.

For legacy PBMs, this is great news, because they make money on rebates and distribution through their own pharmacies, but the high list price of these products are still making it hard for employers to grasp open coverage. 

In 2026, more employers will carve out coverage for GLP-1-based weight management themselves. In turn, they will seek out modern PBMs that offer the flexibility and transparency needed to support low-cost access and embrace the growing direct-to-consumer/ employer movement. Furthermore, we are expecting to see an increased demand in documentation and adherence to lifestyle support paired with medication, as data indicates this drives better results. 

Affordable Biosimilars & Generics Will Redefine Drug Access

2026 will be another breakout year for biosimilars, driven by two major market forces: 

• Low List-Price Disruption: New biosimilar manufacturers are entering the market with an affordable, low list-price business model—mirroring the strategy seen with Stelara’s biosimilars. This approach is designed to counter legacy PBM’s narrative that high-cost options are the only option and, critically, bypass the traditional rebate structure that has historically blocked biosimilar adoption.

• Interchangeability Boost: The U.S. Food and Drug Administration (FDA) is expected to finalize new guidance that will align the regulatory standards for biosimilarity and “interchangeable” status, significantly reducing or removing the need for extensive comparative efficacy and switching studies. This streamlined, science-based approach will allow pharmacists to switch a patient’s prescription to an interchangeable biosimilar without requiring a new prescription from the provider, accelerating adoption to be much more like that of biosimilar medications.

In 2026, we’ll also see some very exciting biosimilars likely come to market for Orencia and Simponi (treatment of autoimmune conditions like Rheumatoid and Psoriatic Arthritis), and Xolair (treatment for allergen-triggered asthma).

Generics will also continue to make a splash in 2026, with several notable generic medications that are expected to launch in the next year for diabetes (Januvia, Janumet, Jentadueto, Tradjenta), a rare disease called Pulmonary Arterial Hypertension (Opsumit, Tyvaso, Adempas, and Uptravi) and Xeljanz which treats autoimmune conditions such as Rheumatoid Arthritis. 

Launches of these biosimilars and generics will continue to mark a huge turning point in plans offering cost-effective treatments to their members who need it most. When cost-based barriers to these treatments are lowered or removed entirely, adherence is shown to improve, as well as overall health outcomes. 

No Reimbursement Reform Will Mean More Independent Pharmacy Closures

Community, independent pharmacies are essential for patient care, with patients visiting their pharmacist 12 times more often than their primary care providers. However, due to worsening, poor reimbursement rates, independent pharmacy margins are severely threatened. Between 2018 and 2021, more U.S. pharmacies closed than opened. Independent pharmacy margins hit a 10-year low in 2022. 

This has led to increasing closures and the creation of “pharmacy deserts”, or areas without a reliable pharmacy presence. In 2024, pharmacies in majority-Black and Latinx neighborhoods closed at rates nearly 10 percentage points higher than those in white neighborhoods—forcing these patients to travel farther or rely on mail-order.

Reimbursement reform is vital. We anticipate a greater push toward a cost-plus reimbursement model that decouples the cost of the medication from the cost to dispense it. Absent legislative intervention or a rush of modern PBM adoption, this threat to patient access and pharmacist livelihood, especially in predominantly minority-dense areas that see higher closure rates, will only intensify. 

Shifting High-Cost Drugs from Medical to Pharmacy Benefits

To achieve significant price payoffs, more companies will utilize medical data to move high-cost, provider-administered J-Code drugs (non-oral medications, such as injections or infusions) off opaque medical benefit plans and onto more transparent, manageable pharmacy benefits.  

This is a key cost-control trend because the pharmacy benefit side offers greater opportunity for price management and the sourcing of lower-cost alternatives. When medication costs become too high to absorb on the medical benefit, this strategic shift provides a necessary path to affordability.

The Future Lies in Dynamic, Self-Adjusting Plans

The accelerating pace of drug discovery, fueled in part by Artificial Intelligence (AI) and its acceleration of the research process, means new medications are hitting the market faster than ever. The current system, limited by rigid, single-year enrollments, is no longer adequate.

The future of pharmacy benefits lies in dynamic, self-adjusting plans that leverage data and technology to optimize for new drugs, employee population changes, and price adjustments throughout the year, not just on January 1st. This shift will require a rethinking of coverage across the industry and will favor modern PBMs built on flexible systems designed to make optimal decisions. Legacy PBMs will get left in the dust and struggle to adopt AI for this exact reason: their businesses are not designed to make smarter, more cost-effective decisions, while AI is. 

The trends for 2026 clearly illustrate that the power is shifting decisively into the hands of the employer and plan sponsor.

For too long, the system has been defined by opacity. The rise of transparent, modern PBMs is not just a trend; it is the structural correction to a broken model. As the market sees new challenges like GLP-1 complexity and opportunities like affordable biosimilars, a clear separation is emerging between the outdated, rebate-driven legacy system and the nimble, data-driven system built on cost-plus transparency.

The competitive advantage in controlling healthcare costs for 2026 and beyond lies in leadership, not latency. By embracing modern partners, you don't just reduce costs; you align your benefits with your members' health and actively participate in building a more affordable, sustainable healthcare ecosystem.