Your Guide to Managing Trend in 2026

If you’re managing pharmacy benefits in 2026, you’re likely facing rising costs, new therapies, and tough decisions. So how do you stay ahead? It starts with understanding what drives trend and how to manage it with confidence.  

Understanding What’s Been Driving Pharmacy Trend 

Up until the 1980s, drug costs were not a major concern for most people or employers funding health benefits for their employees. Drug costs were fairly stable and access was not a concern. Over the last quarter century, however, drug spending has been steadily increasing, shaped by a combination of factors that have contributed to the increasing cost of drugs and the number of people using them. Among the most significant influencers include:

• Technological Advancements: The rise of complex biologic drugs, rare disease therapies (orphan drugs), and new classes for chronic conditions like diabetes have shifted focus from medical to pharmacy spend. These drugs, while effective and at times life-changing, often come at a high cost.
• Specialty Drugs: These high-cost drugs with limited generic alternatives and extended patent protections emerged rapidly and have elevated the cost of the pharmacy benefit over time. 
• Regulatory Environment: Laws have incentivized expensive manufacturer drug development for rare diseases or orphan conditions, while delaying competition. 
• Aging Population & Label Expansions: More people qualify for high-cost therapies as indications broaden. The increase in the number of patients eligible for these therapies further drives demand.

Managing Trend

Despite ongoing efforts to contain costs, pharmacy trend remains a persistent challenge. PBMs and plan sponsors are navigating a complex landscape where member needs, new technology, and financial constraints intersect. Some of the newer solutions and strategies for mitigating trend include:

Maximizing Savings through Biosimilars

Biosimilars present a significant opportunity for plan sponsors to reduce pharmacy benefit costs without compromising clinical outcomes. 

When adopted strategically, biosimilars can deliver savings of 25% to 85% compared to their reference biologic products. These savings are realized not only through lower acquisition costs but also by driving down the price of reference biologics via increased competition. To unlock the full potential of biosimilar savings, PBMs should prioritize biosimilars in formulary design, provide member education, and address barriers such as rebate-driven incentives that may favor higher-cost brands. A biosimilar-first strategy can help control rising pharmacy spend, support better member outcomes, and sustain long-term affordability for both employers and members.

Optimizing 340B Opportunities

The federal 340B Drug Pricing Program enables eligible hospitals and clinics to purchase outpatient drugs at steep discounts. 

Organizations owning pharmacies can maximize 340B savings by ensuring every eligible prescription is captured and processed through 340B-covered entities or contract pharmacies. Using robust data analytics and referral capture programs helps identify missed opportunities and expand eligibility. By actively tracking and claiming all qualifying prescriptions, plan sponsors can unlock substantial discounts and stretch pharmacy benefit dollars further.

Avoid Unexpected Spend Through Preventive Benefits

Preventive benefits are essential but without careful design, they can lead to unexpected costs. The Affordable Care Act mandates $0 cost share for a small list of preventive medications determined by U.S. Preventive Services Tasks Force (USPSTF). The intent of this list is to remove financial barriers and encourage the use of preventive therapies that can help avoid serious health conditions, improve population health, and reduce long-term healthcare costs.

In addition to mandated preventive drug coverage, plan sponsors may choose to offer additional optional preventive benefits. This type of preventive benefit allows certain drugs to bypass the deductible, meaning members receive coverage from the first dollar spent. However, the scope of drugs covered in this type of benefit can vary by plan. 

If high-cost medications are included in this type preventive benefit, members may pay nothing out-of-pocket from day one. This can lead to significant increase in plan spending. For example, in recent years, some plan sponsors experienced a spike in spending when GLP-1 drugs – originally intended for diabetes — were covered under their preventive benefit and then widely used for weight loss. Including such expensive drugs in first dollar coverage can quickly drive up costs. 

Pharmacy networks

Where members fill prescriptions impacts costs. Big box pharmacies may offer convenience, but they often charge more for generics. Mail-order and preferred networks usually deliver better pricing. 

To manage spend without disrupting access, plan sponsors can consider strategies like:

• Grace fills for maintenance medications before requiring mail-order
• Higher copays at big box pharmacies to steer members towards lower-cost options 
• Targeted member letters to encourage use of independent or client-owned pharmacies
• Client-owned pharmacy incentives, if applicable

These measures motivate members toward more cost-effective options while preserving convenience and continuity of care. 

Other Tools and Tactics 

More plan sponsors are stepping up to shape smarter, more sustainable benefits, and PBMs have introduced a range of cost-control strategies to address rising drug spending. 

• Specialty drug tiers, which allow benefits to be tailored to high-cost medications.
• Strategic exclusions for high-cost medications like weight loss drugs from coverage.
• Utilization management programs, such as prior authorizations and step therapy.
• Rebate contracting, especially for brand-name drugs, which offsets some of the cost.
• Strategic partnerships to obtain discounted drug pricing. 
• Copay maximizers and alternative funding programs, which help shift cost and reduce plan liability.
• Stop-loss coverage to protect against the financial impact of rare disease claims.

Strategic Considerations: Reviewing Your Setup

Pharmacy trend isn’t just about what drugs are covered, it’s about how your benefit is structured. Think of your formulary and utilization management as the hardware. Your Summary Plan Document (SPD) is the operating system that determines how everything runs.

As you evaluate your benefit setup, ask:

• Does my SPD align with my formulary and tier structure?
• Are there conflicting setups, like $0 cost share on high-cost drugs under your preventive benefit?
• Is my member cost share ratio still sustainable and appropriate?

Talk with your account team to review your setup. Small adjustments can make a big difference in managing trend.

Let’s Build a Smarter Benefit Together 

ClearScript partners with our clients to navigate pharmacy benefit trends and build solutions tailored to their needs. By offering innovative formulary and benefit design strategies, robust biosimilar adoption program and expertise leveraging 340B, ClearScript provides thoughtful analysis and consultation to helps our clients maximize savings while maintaining high-quality care. 

Whether you’re refining your current approach or exploring new possibilities, ClearScript is here to help you make sense of the complexity and uncover meaningful savings. 

For more insights and information about drug trend management, listen to our latest webinar here, or contact ClearScript for more information.