Employers Brace for Rising Drug Costs and Shifting PBM Expectations | PBMI 2025

As employers look ahead to 2026, rising healthcare costs and the pressures of managing specialty drugs remain top concerns, according to Karen van Caulil, Ph.D., president and CEO of the Florida Alliance for Healthcare Value.

Speaking with Managed Healthcare Executive before her remarks at the Pharmacy Benefit Management Institute’s annual meeting in Orlando, van Caulil focused on the financial strain employers are preparing to face.

She shared that the cost curve is far from leveling off.

Specialty medications, such as cell and gene therapies, are reshaping standards of care while carrying price tags that employers struggle to absorb.

“They don’t just want a vendor that’s processing claims. They want a strategic partner who’s transparent, who’s proactive and is bringing solutions to them and also aligned with their goals,” van Caulil said, pointing to how expectations of pharmacy benefit managers (PBMs) are evolving.

The push for transparency and proactive solutions reflects how employers are rethinking benefit design.

Specialty drugs, once considered niche, are now the main topic of discussions on healthcare affordability. Many therapies offer the potential for cures, but their upfront costs can run into the millions. This act is forcing employers to consider new strategies for cost management and risk sharing.

One recent turning point has been the skyrocketing adoption of GLP-1 therapies for weight management and diabetes. Van Caulil noted that while many employers initially covered these drugs due to strong demand, they quickly saw costs rise.

In response, she said that employers have tightened eligibility requirements, strengthened prior authorization rules and paired coverage with lifestyle management programs.

However, the larger challenge results in preparing for the wave of expensive therapies yet to come, she added.

Employers are experimenting with approaches such as risk pooling, carving out benefits, direct contracting with providers and predictive modeling to anticipate future needs. However, van Caulil did share that no single best-practice strategy has emerged.

For now, employers remain in an “information-gathering and thought leadership mode,” weighing options to ensure financial stability while still providing access to treatments.