On The Radar – 12th Edition
By
Health plans, PBMs, and integrated systems are launching direct-to-patient and cash-pay models to control the medication journey end to end. This move is driven by consumer demand for transparency and competition from independent cash-pay pharmacies.
➡ Why it matters: Payers are no longer just administrators. They are becoming consumer-facing service platforms.
Major manufacturers raised prices on hundreds of drugs at the start of 2026, even as policy initiatives aim to lower costs. These increases hit patients with high deductibles and limited coverage hardest.
➡ Why it matters: List price still matters for employer plans and out-of-pocket exposure.
IRA-negotiated brand prices are now lower than some new generics, leading plans to favor brands while pushing generics into higher tiers. Patients who assume generics are cheaper may pay significantly more.
➡ Why it matters: Formularies are becoming counterintuitive and require closer oversight and education.
While manufacturers agreed to match international pricing for select populations, most Americans remain exposed to routine annual increases. MFN agreements offer targeted relief but do not disrupt the broader pricing cycle.
➡ Why it matters: Structural reform still matters more than headline announcements.
Federal and state legislatures continue advancing PBM reforms focused on transparency, fiduciary duty, and spread pricing bans. California’s SB 41 remains a leading example of enforceable oversight.
➡ Why it matters: PBM contracting is becoming a regulated compliance issue, not just a pricing decision.
Oral GLP-1s, TrumpRx pricing, and increased competition are driving lower prices for some populations. A two-tier system is emerging between cash-pay and privately insured members.
➡ Why it matters: Employers will need clear coverage strategies as pricing and access diverge.
The PBM FAIR Act would impose ERISA fiduciary standards on PBMs, requiring them to act in the best interest of employer plans and disclose compensation structures.
➡ Why it matters: Fiduciary accountability could fundamentally alter PBM incentives.
PBMs continue to face criticism for rebate-driven incentives that favor high-cost drugs and harm independent pharmacies. Public support for reform is growing rapidly.
➡ Why it matters: Transparency is becoming a public expectation, not just an employer demand.
Drugmakers spent more than $150 billion on acquisitions in 2025 to offset upcoming patent expirations. Deals are increasingly milestone-based to manage risk.
➡ Why it matters: Consolidation affects competition, pricing leverage, and long-term innovation.
Investors are treating pharma as a stable income sector despite regulatory pressure, citing dividend strength and predictable pricing floors under the IRA.
➡ Why it matters: Financial incentives and patient affordability remain misaligned.
Reform momentum is coming from three directions: legislation, litigation, and market disruption. State action continues to outpace federal progress.
➡ Why it matters: Pressure on PBMs is sustained and multi-front.
Advocates argue DTC models reduce costs by eliminating rebate-driven intermediaries and forcing manufacturers to compete on price and service.
➡ Why it matters: DTC is shifting from fringe concept to mainstream strategy.
Drugmakers reported record earnings in 2025, driven largely by GLP-1 demand, while patients continue to face high prices and deductibles.
➡ Why it matters: The affordability gap between industry performance and patient experience continues to widen.
Final Thoughts
This edition reinforces a clear theme: transparency, accountability, and direct access are reshaping the pharmacy landscape faster than legislation alone. Employers who understand these shifts will be better positioned to manage spend, protect access, and meet rising fiduciary expectations.
We’ll be back in two weeks with more news you need to know. If you’d like a custom analysis or want to explore SHARx program options for your clients, contact us!
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