Drug Cost Pressures and PBM Reform: Implications for Health Systems and the Role of Pharmacists

Prescription drug spending continues to place a substantial strain on US health systems, impacting operating budgets, patient access to therapy, and long-term sustainability. Although multiple stakeholders contribute to prescription drug costs, pharmacy benefit managers (PBMs) have a significant influence on how medications are priced, reimbursed, and accessed.¹ As PBM practices are more closely examined, health-system pharmacists bring practical expertise to conversations about affordability, access, and value in medication use.

PBMs in the Modern Drug Supply Chain

PBMs were established to manage prescription drug benefits by negotiating prices with manufacturers, establishing formularies, and processing pharmacy claims for health plans.² These functions can generate savings for payers by leveraging scale, promoting formulary adherence, and encouraging the use of lower-cost alternatives. In many cases, PBMs have helped expand access to medications while simplifying benefit administration for employers and insurers; however, the pharmaceutical marketplace has evolved significantly over the past 2 decades. Increased consolidation among PBMs, insurers, and pharmacies, along with the rapid growth of specialty drugs, has added new complexities to benefit management. As a result, some PBM practices have drawn attention for potentially creating misaligned incentives or limiting transparency for plan sponsors, providers, and patients.²

Drug Cost Pressures and Health-System Challenges

Health systems face increasing drug cost pressures that strain pharmacy budgets and affect patient affordability and adherence. PBM reimbursement structures can create variability in net drug costs, making overall spending more difficult to predict and manage. A common example is spread pricing, in which a PBM charges a health plan more for a medication than it reimburses the dispensing pharmacy, retaining the difference.³

While this can provide predictable revenue for PBMs, it may obscure actual drug costs and limit health systems’ ability to evaluate value across the medication-use process. Rebate-driven formulary design has also raised concerns about alignment with clinical and economic value. Manufacturer rebates tied to higher list prices may influence formulary placement even when lower-cost therapeutic alternatives exist. While rebates can lower net costs for payers, they do not consistently reduce patient out-of-pocket expenses at the point of sale.²

Together, these factors can influence formulary decisions, specialty pharmacy operations, and patient access, particularly for high-cost therapies such as oncology, immunology, and rare disease treatments.⁴

Rising Interest in PBM Reform

Rising prescription drug costs and complex pricing practices have placed PBMs under increasing scrutiny at both the federal and state levels.⁵ Current reform efforts aim to improve transparency, enhance oversight, and ensure that PBM incentives prioritize patient access and value-based care rather than being driven solely by list prices or hidden rebates.
Professional organizations, including the American Medical Association and pharmacy advocacy groups, have called for greater transparency in the disclosure of PBM contracts, rebates, and administrative fees. This transparency helps providers and plan sponsors understand actual medication costs, anticipate coverage limitations, and make informed decisions that support optimal patient care.⁵

At the state level, legislation has addressed practices such as spread pricing, audit procedures, and PBM ownership of pharmacies to improve transparency and promote fair competition. The legislation defines the parameters of PBM involvement in pharmacy benefit and formulary management while balancing clinical outcomes and cost.

For pharmacists, staying informed about these changes is essential, as PBM policies directly impact patient access, out-of-pocket costs, and the ability to deliver safe, effective therapy.

Opportunities for Health-System Pharmacists

Health-system pharmacists play a key role in PBM reform by integrating their clinical expertise with a strong understanding of operational and financial workflows. Their insights help ensure that efforts to manage drug costs do not compromise patient care.⁶

Pharmacists can contribute in the following key areas⁶:

• Formulary leadership: Guiding formulary decisions to reflect evidence-based medicine, real-world outcomes, and total cost of care.
• Data analysis: Collaborating with finance and analytics teams to evaluate the impact of PBM contracts on drug spending, patient access, and adherence.
• Contract evaluation: Advocating for transparent PBM agreements that provide health systems with clarity on pricing structures and performance metrics.
• Education and advocacy: Engaging clinicians, administrators, and policy makers to illustrate how PBM practices affect patient care and system sustainability.

Overall, pharmacists help ensure that financial and operational decisions support both high-quality patient outcomes and the goals of value-based care.

The Evolving Role of Pharmacists in Drug Cost Solutions

Health systems will continue to face drug cost challenges as specialty medications become more prevalent across therapeutic areas. PBMs will remain an integral part of pharmacy benefit management as evolving market dynamics reinforce the need for reforms that emphasize transparency, accountability, and patient-centered outcomes.

For health system pharmacists, this presents an opportunity to move beyond traditional cost containment strategies and engage more directly in conversations about value, access, and sustainability. As trusted experts in medication management and clinical care, pharmacists bring essential clinical expertise to PBM reform efforts, ensuring cost containment does not come at the expense of patient-centered care.

REFERENCES

1. Bollmeier SG, Griggs S. The role of pharmacy benefit managers and skyrocketing cost of medications. Mo Med. 2024;121(5):403-409. Accessed February 3, 2026. https://pmc.ncbi.nlm.nih.gov/articles/PMC11482839/

2. Mattingly TJ 2nd, Hyman DA, Bai G. Pharmacy benefit managers: history, business practices, economics, and policy. JAMA Health Forum. 2023;4(11):e233804. doi:10.1001/jamahealthforum.2023.3804

3. New HPC analysis highlights need for transparency in drug pricing practices of pharmacy benefit managers. News release. Massachusetts Health Policy Commission. June 5, 2019. Accessed February 3, 2026. https://masshpc.gov/news/press-release/new-hpc-analysis-highlights-need-transparency-drug-pricing-practices-pharmacy

4. FTC releases second interim staff report on prescription drug middlemen. News release. Federal Trade Commission. January 14, 2025. Accessed February 3, 2026. https://www.ftc.gov/news-events/news/press-releases/2025/01/ftc-releases-second-interim-staff-report-prescription-drug-middlemen

5. Advocacy update spotlight on pharmacy benefit managers under scrutiny. American Medical Association. August 1, 2025. Accessed February 3, 2026. https://www.ama-assn.org/health-care-advocacy/advocacy-update/aug-1-2025-advocacy-update-spotlight-pharmacy-benefit-managers

6. Moore DC, Colella A, Douglas JS, Shlom EA, Vanderloo JP, Alabi F. Incorporating pharmacoequity in the formulary review and evaluation process: opportunities for health-system P&T committees to address health disparities and inequities. Am J Health Syst Pharm. 2025;82(13):e637-e640. doi:10.1093/ajhp/zxae370