Q3 2026 Pharmacy Benefits Trends

WHAT MATTERS NOW

Q3 2026 has been quite a quarter in the pharmacy benefit landscape. The FTC has wrapped up its cases and reached settlements with the Big 3 PBMs, the National Alliance of Healthcare Purchaser Coalitions released its largest survey with some interesting findings for employer-sponsored health plans, and we saw several new drug approvals across a variety of conditions worth keeping an eye on.

Here’s the quick synopsis and what it could mean for your plan:

• FTC Settlements Are Now Complete: CVS Caremark finalized its settlement on July 14, making it the latest of the three major PBMs to enter under consent orders that include greater transparency, bans on spread pricing, and requirements to separate PBM compensation from list-price benchmarks, following the Express Scripts settlement and OptumRx proposed consent agreement earlier this year.
• Pulse of the Purchaser 2026: The National Alliance of Healthcare Purchaser Coalitions surveyed 408 employers representing 3.7 million lives. One of the big takeaways? Employers expect healthcare costs to increase 7.7% heading into 2027. The survey also found that employers with access to full claim-level data are much more likely to take action on their healthcare purchasing strategies than those without that visibility.
• GLP-1 Coverage Continues to Evolve: This quarter, we’ve seen headlines about several well-known employers changing their approach to GLP-1 coverage. Companies like Cigna, Starbucks, and PepsiCo have pulled back, while others, like Bank of America, are adding coverage and viewing GLP-1s as an investment in their members. Additionally, Mounjaro recently received FDA approval demonstrating cardiovascular protective benefits, adding another piece to the conversation around its clinical value.
• Once-Weekly Insulin Arrives: For the first time, we now have once-weekly insulin options with Awiqli from Novo Nordisk and Onswik from Eli Lilly entering the market. It will be interesting to see whether the added convenience of once-weekly dosing changes utilization behavior and how providers and patients respond to other insulin therapy options.
• New Drugs, New Decisions: We continue to see more development around different ways to administer medications, giving patients more options in how they take their drugs. One example is the recently launched first oral PCSK9 inhibitor, Lipfendra, which gives patients an option beyond the existing injectable versions. Other notable approvals, including Xocova, Rasonque, and Garzulys, will also be in the queue for formulary review. Biosimilar momentum also continues, with new approvals across oncology, ophthalmology, and diabetes.

QUARTERLY PULSE: TRENDS SHAPING THE LAST 90 DAYS

Big 3 PBM Consent Orders Status Update After FTC Action

In Q1, we covered the FTC’s February settlement agreement with Express Scripts. During Q2, the FTC continued considering a potential agreement with CVS Caremark, which was announced on July 14. That made Caremark the latest of the three major PBMs to reach settlement terms, after the case involving OptumRx remains unresolved.

For employers and plan sponsors, the proposed consent orders signal greater scrutiny of PBM compensation and the financial incentives behind formulary decisions. The agreements outline additional reporting requirements and options for plan sponsors to move away from spread pricing and rebate guarantees, and they also address formulary practices that favor higher-list-price medications over lower-list-price equivalents.

What the FTC Settlements Mean

• PBM compensation is being separated from drug list prices: Under the standard offering, manufacturer fees paid to the PBM and its GPOs cannot be tied to favor a higher-priced drug.
• Spread pricing is being phased out: The standard offering will give plan sponsors a way to move away from spread pricing and rebate guarantees, with the settlement outlining additional requirements around the standard offering.
• More rebates can reach members at the pharmacy counter:The default option requires rebates to be passed through to members at the point of sale, with member out-of-pocket costs based on the plan’s contracted rate minus applicable rebates rather than the full list price.
• Lower-list-price drugs get more protection: The PBM cannot discriminate against lower-WAC versions of drugs on its standard formularies, which could make the relationship between rebates, formulary placement, and drug prices something employers will want to watch more closely.
• Plan sponsors get more transparency: The settlement includes additional transparency requirements, including greater access to information that can help employers better understand their pharmacy spend and PBM arrangements.
• Insulin affordability programs: CVS Caremark will be required to offer affordability programs that cap members’ out-of-pocket insulin costs when applicable, although plan sponsors can opt out. The FTC estimates the CVS Caremark settlement could result in up to $8.5 billion in savings over 10 years, along with up to another $4.5 billion in potential savings from point-of-sale rebates.

What Employers Should Do Now

Use these new requirements as a benchmark when reviewing your PBM contract. The settlements give employers another reference point for what PBM transparency and pricing practices can look like. If your current contract doesn’t provide things like clear compensation terms, limits on spread pricing, or meaningful claim-level transparency, this is a good time to take another look.

Pulse of the Purchaser: Data Access is the Difference

Each year, the National Alliance of Healthcare Purchaser Coalitions surveys employers to understand the challenges shaping healthcare benefits. Its 2026 Pulse of the Purchaser survey highlights growing cost pressures and the importance of data access in managing pharmacy benefits.

Key findings include:

• Survey participation:408 employers representing 3.7 million covered lives responded, with 80% reporting they were self-insured.
• Projected cost increases: Employers anticipate a 7.7% increase in healthcare costs heading into 2027, before making plan design changes.
• Healthcare spending:Hospital and facility costs account for 30.5% of total healthcare spending, followed by prescription drugs at 21.1%.
• Data access:While 84.5% of employers have access to aggregate vendor data, only 65.3% have complete claim-level access, and just 58.6% are permitted to audit their own files.

The survey also found that employers with full claims data access tend to use more strategies to manage their pharmacy benefits.

For employers, that visibility creates an opportunity to make more informed decisions about pharmacy spending. Claim data helps identify which prescriptions are driving costs and whether a PBM is delivering on its financial commitments.

The Big Three PBM Shift Continues

The shift away from the Big 3 PBMs, Express Scripts, CVS Caremark, and OptumRx, continues. The survey found the combined market share dropped from 63% to 54% in just one year. Smaller employers drove much of that change, but larger employers are looking at their options too. Among current Big 3 PBM clients, 56% are considering switching PBMs within the next one to three years.

There’s also a clear difference in contract transparency. One in four employers with the Big 3 as their PBM said they don’t know what’s included in their PBM contract, twice the rate compared to employers using an alternative PBM. Non-Big 3 PBM clients also reported stronger contract protections around spread pricing, formulary requirements, affiliated entities, and PBM compensation.

Employer interest in PBM reform is growing as well, with support now at 87.6%. Those with full claims data are also significantly more likely to engage in healthcare policy discussions.

The takeaway is simple: employers are paying closer attention to their PBM relationships, contracts, and the transparency behind how their pharmacy benefits are managed.

What This Means for Your Plan

The Pulse of the Purchaser data reinforces that you can’t manage what you can’t see.

Full claim-level data, independent audit rights, and transparency into how your PBM is paid give employers a clearer picture of where their pharmacy dollars are going, how much they are paying for services, and the information they need to make better decisions.

And as the PBM landscape continues to change, that transparency matters even more. Whether you’re preparing for an RFP or trying to understand your pharmacy spend, it starts with having the right data and a PBM willing to show you what’s behind it.

GLP-1 Coverage at a Crossroads

The GLP-1 landscape in Q3 2026 continues to be a balancing act between the clinical case and the cost of covering these medications. Employers are still figuring out how to manage access as the GLP-1 landscape continues to change quickly.

The Coverage Pullback

According to the International Foundation of Employee Benefit Plans’ 2026 survey, more than 90% of employers cover GLP-1s for diabetes, but only 36% also cover them for weight loss and obesity.

Headline news this year has also highlighted several large employers taking different approaches to GLP-1 coverage. Companies like Cigna, Starbucks, and PepsiCo have changed weight-loss coverage, while Bank of America has taken a different approach and continues to view GLP-1 coverage as an investment in employee health.

Bank of America has pointed to the potential long-term health benefits of these medications and is also using its size to push for lower prices. This highlights the different ways employers are approaching how they balance the cost of covering GLP-1s with the potential value they can provide to members and the plan over time.

The Pulse of the Purchaser survey adds another layer to the conversation. About 68% of employers are either already limiting GLP-1 access or considering limits to certain populations. More employers are also turning to vendor-managed GLP-1 programs to manage access and cost. Use of these programs has grown from 11% of employers in 2024 to 19% in 2025, and up to 28% in 2026.

And the financial concern is understandable. The potential population eligible for GLP-1s is also much larger when these medications are covered for weight loss. That creates a very different cost equation for employers compared with covering these drugs primarily for diabetes.

The Landscape is Still Moving

At the same time, the GLP-1 landscape is far from settled. We’re already seeing meaningful price changes beginning in 2027, with manufacturers announcing lower prices for some GLP-1 products. Those changes could improve the economics for employers, but the impact will depend on the net cost to the plan after rebates, discounts, and other pricing arrangements.

And the pipeline is worth watching, too. New GLP-1s and next-generation versions are moving through development, including drugs that may offer different dosing schedules or combinations. In other words, the GLP-1 category itself is likely to look very different over the next few years.

That creates an interesting dynamic for plan sponsors. Coverage decisions made today are being made against a market that could look materially different by 2027 and beyond.

That doesn’t necessarily mean employers should constantly change their benefit strategy, but it does mean GLP-1 coverage probably shouldn’t be a “set it and forget it” decision.

Whether an employer covers GLP-1s for diabetes only, includes them for weight loss, uses a managed program, or applies utilization management, the key is to watch market changes and understand how they affect the plan. That doesn’t necessarily mean employers should constantly change their benefit strategy, but it does mean GLP-1 coverage probably shouldn’t be a “set it and forget it” decision.

FROM THE PHARMACIST’S DESK

Mounjaro Gets a Heart Indication

On August 28, 2026, the FDA approved Mounjaro (tirzepatide) to reduce the risk of major cardiovascular events, including heart attack, stroke, and cardiovascular death, in adults with type 2 diabetes who are at high cardiovascular risk.

The approval was based on a large study of more than 13,000 people that compared Mounjaro with Trulicity, another GLP-1. Mounjaro showed an 8% lower rate of major cardiovascular events, adding another piece of clinical evidence for potential benefits of GLP-1s beyond blood sugar control.

So… what does this mean for employer plans?

Mounjaro is now the first dual GIP and GLP-1 medication with a demonstrated cardiovascular benefit. This adds another consideration when appraising Mounjaro and how GLP-1 coverage fits into the broader pharmacy benefit strategy. While this alone may not significantly change current utilization, it adds another factor for employers to consider as they evaluate these medications.

The bigger takeaway is that the GLP-1 conversation continues to evolve. These medications are no longer thought of only through the lens of diabetes or weight loss. As more evidence emerges around other health outcomes, employers will want to monitor how that may impact coverage decisions and utilization.

Once-Weekly Insulin Arrives

Once-weekly insulin is also worth keeping track of.

After more than two decades without a new type of long-acting insulin, 2026 has introduced two once-weekly options: Awiqli (insulin icodec) from Novo Nordisk and Onswik (insulin efsitora alfa) from Eli Lilly.

Awiqli launched in August at a $99 list price per package, while Onswik was approved in September with pricing still to come. Both are designed to provide similar blood sugar control to daily insulin but with the convenience of just one injection per week.

The key now is where these new options fit into the pharmacy benefit.

This creates a brand-new category for formularies, with two major manufacturers now competing in the space. As Onswik pricing becomes available, plans need to adapt to product price and positioning, including whether the convenience of weekly dosing provides enough value to change how these products are covered.

Arrive New FDA Approvals to Watch

Q3 also brought several new drug approvals that highlight some of the changes we’re seeing across the broader pharmacy landscape. While not every new drug will meaningfully impact every plan, these are a few worth keeping on the radar as they enter the market.

• Xocova (ensitrelvir) was approved for preventing COVID-19 following exposure and carries a $1,400 list price for a five-day course. Because it must be started within a relatively short window after exposure, plans will want to balance appropriate utilization controls with making sure those controls don’t create unnecessary delays.
• Lipfendra (enlicitide) was approved as the first oral PCSK9 medication for lowering cholesterol. With an annual list price of $3,833, it enters a market that already includes lower-cost generic options and injectable PCSK9 medications. The fact that this medication is taken by mouth, along with its lower list price, makes it worth watching as plans consider where it fits their formularies.
• Rasonque (daraxonrasib) was approved for certain patients with metastatic pancreatic cancer and carries a monthly list price of $39,800. Like other high-cost oncology drugs, plans will want to keep an eye on utilization and how this new treatment fits into specialty drug management.

These are good examples of why it’s important for employer plans to stay updated on more than just the latest FDA approvals. They also show how quickly the drug market continues to evolve, from new ways of taking existing medications (like moving from injectable to oral options with PCSK9s) to the continued development of high-cost treatments for complex and specialty conditions.

Not every new drug will become a major cost driver, but understanding these trends early gives plans and brokers time to think about coverage and potential impacts before utilization starts to build.

Biosimilars Keep Moving

One biosimilar worth looking closer at is Omlyclo, an interchangeable biosimilar to Xolair. Used to treat conditions such as asthma and chronic hives, it launched in Q3 at a 15% discount to Xolair’s list price.

For plans with members on Xolair, this creates a new opportunity to introduce competition into the category and potentially lower costs. It will be worth watching how PBMs position Omlyclo on their formularies and, more importantly, what the actual net savings look like for employers.

Biosimilar competition is also continuing to gain traction in other categories. Ustekinumab (Stelara) biosimilars reached 42% market share in Q3, while adalimumab (Humira) biosimilars surpassed 80%. With significant discounts now available in several of these categories, biosimilars continue to be an important area for specialty drug savings.

And there’s more competition coming.

Three additional biosimilars were approved in Q3: Ennumo for Neulasta, Ranluspec for Lucentis, and Garzulys for Novolog. None have launched commercially as of Q3, but these products are worth watching as they move toward the market and create additional competitive opportunities.

And this is where the PBM contract matters.

Just because a lower-cost biosimilar is available doesn’t automatically mean the employer captures those savings. Formulary placement, rebates, guarantees, and pricing pass-through can all affect the actual plan cost.

As more biosimilars enter the market, plan reviews should identify whether those savings go back to the employer.

What We’re Watching at US-Rx Care

At US-Rx Care, we’re keeping a close eye on these new drugs and biosimilars. As new options become available, we’re reviewing where they may make sense within our formularies and where there may be an opportunity to improve value for our clients.

We want to ensure our formularies include appropriate treatment options while also looking for opportunities to use competition and lower-cost alternatives to help manage overall drug spend. As the market continues to change, we’ll keep evaluating new opportunities for our formularies to keep up with what’s happening.

PARTNER SPOTLIGHT: THE US-RX CARE APPROACH

Built for the Market the Data Demand

The 2026 Pulse of the Purchaser survey reinforces what US-Rx Care has believed since we started in 2007: employers need the right data and transparency to make better decisions about their healthcare costs.

It’s not just about how much you’re spending, but about seeing what you’re paying for, understanding what is driving that spend, and having the information needed to do something about it.

That’s been at the core of how we built our model from the beginning.

• Fiduciary model: US-Rx Care works with the plan sponsor and its members in mind. Our pharmacy benefit decisions are focused on finding the right balance between appropriate treatment, member access, and overall plan cost.
• No conflicting financial incentives: We don’t make money from spread pricing, markups, retained rebates, or pharmacy ownership. We also don’t own mail-order or specialty pharmacies that could influence where medications are filled.
• 100% rebate pass-through: Rebates and discounts received from manufacturers are passed back to the plan, which has been part of our model from the start,
• Full claim-level transparency: Employers have access to the detailed data behind their pharmacy benefit. That means you can look beyond an aggregate report and understand which drugs are being used and what they cost before considering opportunities to make potential changes.
• A focus on value: We look for opportunities to lower pharmacy spend without taking benefits away from members. That can mean optimizing formularies, evaluating new FDA-approved treatments, identifying appropriate lower-cost alternatives, or ensuring savings from biosimilars make their way back to the plan.

The pharmacy market continues to move towards greater transparency, and our job is to keep up with and explain those changes to our clients and their members.

As the market continues to evolve, we’ll continue doing what we’ve always done. We follow the data and make decisions with our clients and their members best interests in mind always.

THE CONFERENCE COLLECTION

Q3 2026: Where the US-Rx Care Team Has Been

The US-Rx Care team continued engaging with employers, consultants, and healthcare leaders across the country throughout Q3 2026. Some industry events we’ve attended:

• HCAA TPA Summit (Nashville, TN | Jul 27–29)
• Health Rosetta Fest (Nashville, TN | Jul 29–31)
• FSHP Annual Meeting (Orlando, FL | Aug 8–10)
• HCBC Conference (Houston, TX | Aug 26–27)

Q4 2026: Where to Find the US-Rx Care Team

Looking ahead, the US-Rx Care team will continue attending major industry events. We look forward to connecting with employers, advisors, and industry partners throughout the remainder of 2026.

• Tradeswomen Build Nations (Houston, TX | Oct 9–11)
• SIIA National Conference (Phoenix, AZ | Oct 11–13)
• IFEBP Conference (New Orleans, LA | Oct 25–28)
• National Alliance of Healthcare Purchaser Coalitions (Arlington, VA | Nov 16–18)
• Dallas-Fort Worth Business Group on Health (Dallas, TX | Dec 2–3)
• Florida Alliance for Healthcare Value (Orlando, FL | Dec 9)
• Purchaser Business Group on Health Annual Summit (Nashville, TN | Dec 9–11)

COMING SOON

Details will be shared in future editions as they become available.