The Evolution of Pharmacy Benefits: Trends Employers Should Watch Over the Next Five Years

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The Evolution of Pharmacy Benefits: Trends Employers Should Watch Over the Next Five Years

The most expensive line item in an employer’s pharmacy plan may not be a drug. It may be uncertainty.

Specialty medications are consuming a growing share of prescription spending. GLP-1 drugs are forcing difficult decisions about access, affordability and long-term coverage. Federal regulators are demanding a clearer accounting of how pharmacy benefit managers are paid, while employees increasingly expect prescription benefits to be easier to understand and use.

Together, those pressures have pushed pharmacy benefits out of the back office. Decisions involving formularies, clinical programs, data access and vendor contracts can now affect financial planning, workforce trust and whether employees receive treatment without avoidable delays.

AffirmedRx is among the industry participants advocating for a more accountable and member-focused approach. Structured as a Public Benefit Corporation, the pharmacy benefit manager operates on a flat administrative fee, passes manufacturer price concessions to clients and provides Patient Care Advocates who help members navigate prescriptions, coverage questions and potential barriers to treatment.

“Employers are being asked to manage more complexity at the same time that employees expect a simpler and more responsive experience,” an AffirmedRx spokesperson said. “That makes financial clarity, reliable data and meaningful clinical support increasingly important. The organizations that understand what is driving their pharmacy costs will be better positioned to make decisions that support both their workforce and their long-term benefits strategy.”

AffirmedRx’s model reflects a broader shift taking place across the pharmacy benefits industry, where employers are demanding clearer financial arrangements, greater access to claims data and more support for members managing complex therapies. Those expectations will continue to influence how plans are designed, measured and evaluated during the next five years.

Here are five trends employers should watch as pharmacy benefits evolve through 2031.

No 1. – Specialty Medications Will Redefine Financial Risk

Specialty medications are transforming the treatment of cancer, autoimmune diseases and other complex conditions. They are also creating greater financial uncertainty for employers because a small number of high-cost claims can significantly disrupt an annual pharmacy budget.

IQVIA reported that specialty medicines accounted for $262 billion, or 53% of U.S. net medicine sales, in 2024. The firm also projected that patent expirations could affect $91 billion in branded revenue over the following five years, potentially creating more opportunities for generic and biosimilar competition (source).

Biosimilars can reduce costs, but savings are not automatic. Results depend on formulary placement, physician adoption, contracting arrangements and whether the plan favors the medication with the lowest overall cost.

Employers should ask where specialty prescriptions are filled, whether the PBM is affiliated with the dispensing pharmacy and how lower-cost clinical alternatives are evaluated. They also need reporting that explains what the plan paid, why a particular medication was selected and whether the decision delivered appropriate value for both the member and the organization.

Over the next five years, the strategic question will extend beyond the price of an individual drug. Employers will need to determine whether their pharmacy benefits partners can anticipate financial risk, evaluate emerging alternatives and clearly explain the decisions behind specialty-drug spending.

No 2. – GLP-1 Strategy Will Move Beyond Yes or No

GLP-1 medications have become a stress test for employer-sponsored coverage. Workers see the potential for health improvement. Employers see a large eligible population and a budget that can move quickly.

KFF found that 43% of employers with at least 5,000 workers covered GLP-1 drugs for weight loss in 2025, up from 28% a year earlier. More employers are adding requirements such as lifestyle programs, case management or clinical review.

The next five years will be less about whether an employer covers GLP-1 therapy and more about how that coverage is designed. Evidence-based eligibility rules, continued-treatment standards and clinical follow-up can help manage spending without turning prior authorization into an obstacle course.

Employers will also need a broader definition of value. A pharmacy claim shows the cost of treatment, but not whether diabetes control improved, cardiovascular risk changed or another medical expense was avoided. Connecting pharmacy and medical information will be essential.

The strongest programs will be clear enough for employees to understand and flexible enough to evolve as new drugs, indications and pricing structures reach the market.

No 3. – Transparency Will Have to Survive an Audit

The pharmacy benefit industry has used “transparency” so frequently that the word has nearly lost its meaning. Regulation is beginning to give it teeth.

The federal Prescription Drug Data Collection program requires insurers and employer-based health plans to report information on drug spending, frequently prescribed medications, rebates, premiums and patient cost-sharing. In January 2026, the U.S. Department of Labor proposed a rule requiring PBMs serving self-insured group health plans to disclose compensation, including rebates, spread and certain pharmacy payments.

The message is straightforward: Fiduciary responsibility requires more than accepting a vendor’s summary.

Contracts should define every revenue stream, guarantee access to claim-level data and provide audit rights that can be used. Employers should be able to reconcile rebates, identify spread pricing and understand whether affiliated businesses receive compensation connected to the plan.

AffirmedRx’s model reflects where the market is moving. It provides full claim-level data, passes through manufacturer price concessions and separates its compensation from the price and volume of prescriptions.

“Transparency should not be a presentation delivered once a year,” the spokesperson said. “It should be an operating condition of the relationship, one that allows an employer to follow the money, test the contract and make decisions from its own data.”

No 4. – Data Access Will Matter Only When It Leads to Action

A benefits team can receive hundreds of pages of reporting and still lack an answer to the most important question: What should we do next?

Over the next five years, employers will expect pharmacy data to arrive faster, connect across vendors and point toward action. They will want to see where prior authorizations are stalling, which prescriptions are being abandoned, what is driving specialty trends and whether a formulary change worked.

Data ownership will become as important as dashboard design. Employers should know whether they can retrieve information in a usable format, share it with an outside analyst and carry it into a new vendor relationship.

Artificial intelligence may help identify risks or savings opportunities, but employers should resist black-box recommendations. A useful system should explain why it flagged a member or medication, what action it recommends and where a qualified clinician enters the process. URAC has emphasized transparency, independent oversight and explainable systems as health care organizations adopt AI tools.

The future will not belong to the organization with the most data. It will belong to the one that turns information into a timely, defensible decision.

No 5. – Member Experience Will Become a Clinical Metric

Employees do not experience a PBM contract. They experience a rejected claim, an unexpected copay or a prescription that never reaches the pharmacy.

That friction can affect whether treatment begins or continues. The Employee Benefit Research Institute reported that 35% of privately insured GLP-1 users surveyed had stopped taking the medication. Four in 10 cited affordability, while one in seven said the drug was not covered.

Those findings show why member experience is more than a customer-service measure. Confusion can lead to nonadherence. Delayed authorizations can postpone treatment. Members who cannot reach someone capable of resolving a problem may simply give up.

Employers will increasingly examine resolution times, prescription abandonment, clinical outreach and coordination among patients, providers and pharmacies. AffirmedRx’s Patient Care Advocate model reflects that shift by helping members address authorizations, affordability, adherence and benefit questions.

The company earned URAC accreditation in pharmacy benefit management in June 2025 and works with organizations including Amazon Pharmacy, Mark Cuban Cost Plus Drug Company and CenterWell Specialty Pharmacy.

Technology will remain essential, but the highest-value moments may still require a person who understands both the clinical stakes and the pharmacy system.

By 2031, pharmacy benefits will not be judged by rebate guarantees alone. Employers will ask whether specialty costs are managed responsibly, GLP-1 coverage is clinically sound, data supports decisions and members can obtain care without becoming experts in the system.

“The next era of PBM reform must be measured by what employers can see and what members can experience,” an AffirmedRx spokesperson said. “Doing the right thing means removing incentives that drive unnecessary costs, making clinical decisions for the right reasons and helping people access the medications they need without navigating the system alone.”