The pharmacy benefit management (PBM) request for proposal (RFP) season is right around the corner, and, if industry experts are correct, 2026 will be one of the most consequential RFP seasons employers have ever faced.

Recent state and federal legislation all but guarantees major changes are imminent for traditional PBM cost models, reshaping the market. While recent survey data suggest nearly two-thirds of employer plan sponsors are interested in moving away from the “Big 3” PBMs, the industry is also beginning to shift the focus on fiduciary obligations, rising utilization of GLP-1s, data access and specialty drug costs.

At the same time, skyrocketing healthcare costs are forcing plan sponsors to figure out how to control ongoing and future costs before the next blow to their bottom lines becomes too painful to absorb.

Plan sponsors and fiduciaries must quickly learn to balance providing adequate benefits to employees and their families, controlling costs and becoming experts in the services and solutions they are procuring.

How to improve PBM procurement

To achieve this success, here are the top recommendations all plan sponsors should follow for the 2026 PBM procurement season:

1. Understand how to value drug mix from one PBM to another; it’s the most important piece of the procurement process.

PBMs have historically focused on unit costs (discounts, dispensing fees, rebates and administrative fees) rather than on drug mix (formulary, prior authorization criteria, etc.), which ultimately drives 50% or more of future drug spend. This has allowed the traditional PBM to maintain power. Some RFPs, however, do a better job of exploring and comparing the value of drug mix between PBMs. If the RFP only asks about unit cost, it’s a near guarantee that the PBM with the highest rebates will look the best, every time.

Every RFP should pose questions that assess clinical program rigor as well as the financial outcomes associated with each program, which should be included in the overall financial guarantee. Some examples of questions to ask about programs that are more impactful to future drug spend include:

1. How do PA success rates compare by therapeutic class?
2. Can we compare the “low value” drug use between PBMs?
3. What are the auto-refill criteria, and can I review over-refill rates by drug between PBMs?

2. Go “all-in” on biosimilars.

Specialty drug spend continues to dominate pharmacy spend for commercial plan sponsors, with specialty utilization averaging 2% across most plan sponsors and accounting for nearly 50% of spend. This is further compounded by lower-cost biosimilars for Humira® that have entered the market over the last couple of years, with only a few biosimilars for Stelara® being approved in 2025.

Over the next decade, we should expect to see many more high-cost biologics come to market with lower-cost biosimilars, which will positively impact ingredient costs in PBM RFP evaluations. Despite this potentially leading to lower rebates for specialty drugs, plan sponsors should continue adopting biosimilars as the market expands, because their value will grow in tandem.

3. Prepare finance leaders for lower rebates.

Almost every year, I suggest that plan sponsors break their addiction to rebate checks. This year, this suggestion is even more important. With the surge of biosimilars already on the market and the impact of the Jan. 1 implementation of the most recent round of Medicare drug price negotiations for 2026, total rebate value as a percentage of drug spend is declining due to the removal of the average manufacturer price cap (AMP Cap) in 2024.

The good news is that ingredient costs are down as a result. It’s still important for plan sponsors to pay close attention to their data, because some PBMs may continue to offer higher rebate guarantees, potentially offset by rebate credits, which can create confusion—especially during the RFP process. These credits, however, are not always accurately identified and accounted for. Even experienced benefits consultants and plan sponsors can be misled about the impact of rebates on total plan spend. Looking at PBMs that offer “lowest net cost” formularies or favor generics and biosimilars—and propose rebates on AMP Cap drugs at the reduced rate—can help.

4. Stay informed of state and federal regulatory changes.

It has been a very busy start to 2026, and some substantial PBM reforms have already been signed into law. With states making sweeping changes relative to PBM reform and the federal government following suit, plan sponsors should expect  more prescription drug pricing and PBM reform initiatives in the coming years. These changes often have a positive impact on plan sponsors, but they can pose significant challenges for traditional PBMs.

Ask your PBM partner about how the following will impact their business, and listen carefully for any answers that seem inconsistent with your experience or the intent of the new laws:

• A ban on spread pricing
• The reporting requirements
• Delinking sources of revenue
• Full pass-through of all pharmaceutical manufacturer revenue

If you don’t believe what you hear, you may need to look for a new PBM partner that offers an innovative, financially aligned model and can help you “future-proof” your pharmacy benefits plan.

Bonus top-of-mind Rx issues that can help with plan optimization in 2026:

5. Consider the value that generous generic programs (e.g., $0 generic co-pays) can add.

It may seem counterintuitive to offer more drugs at a $0 co-pay when considering cost savings and avoidance measures. Generally speaking, I’ve seen employer plan sponsors have an average Generic Dispensing Rate (GDR) of about 85% to 87%, with brand and specialty making up the remainder. Even with utilization averaging 85%, generics account for only about 15% of plan costs—which is further complicated by traditional PBMs’ contracting practices and the lack of consistent definitions for brand and specialty drugs.

I’ve seen generous generic programs drive between 2% and 5% of brand claims to generic alternatives. The result is a “win-win” for the plan and its members if executed correctly. However, a generous generic program may backfire if a plan sponsor’s PBM formulary is primarily rebate-driven, so exercise caution if you are in this situation. One option is to consider adding only targeted generics for chronic conditions to a $0 copay program, as this can often help lower healthcare costs by improving medication adherence.

6. Prepare for higher enrollments in self-funded commercial plans.

With the elimination of the pandemic-era enhanced Affordable Care Act (ACA) subsidies, reductions in the federal workforce and overall stagnation in the U.S. job market, many commercial plan sponsors should expect higher enrollment in 2026 than in the 2025 plan year. A healthier member population can lower average per-member per-month (PMPM) spend, but it may also introduce new cost pressures the plan hasn’t previously faced.

With medical and pharmacy spend rising, it is more critical than ever to carefully evaluate vendor partners’ fee structures and focus on how the plan can provide its members with a similar level of benefits while keeping overall costs low.

As we move further into 2026, the urgency around the procurement process will only intensify, leaving plan sponsors with little time to make the most impactful decision for their plan. Starting early is the best advice I can offer, and plan sponsors must ensure they receive relevant, unconflicted advice from their brokers and consultants.

This year, the stars have aligned, and buying power has shifted. Plan sponsors can finally choose a PBM partner better positioned to help meet their fiduciary obligations and plan members’ needs.