Happy New Year! We asked leaders in managed care, including members of our editorial advisory board, to make some predictions about what the important developments in U.S. healthcare might be in 2026.

Growth in radiopharmaceuticals will challenge payers and PBMs

Radiopharmaceuticals — radioactive compounds with an isotope that can target specific cancer cells — are gaining momentum as a leading oncology therapy with the potential to reshape the healthcare landscape. As diagnostic and therapeutic applications of radiopharmaceuticals continue to evolve, the clinical pipeline of trials has put these drugs on the radar of many health plans.

The regulatory environment around radiopharmaceuticals is also in flux. In 2023, the FDA reclassified radiopharmaceuticals from devices to drugs, paving the way for Pharmacy and Therapeutics Committee oversight. And earlier this year, the CMS Final Rule also allowed for separate reimbursement of diagnostic radiopharmaceuticals when they exceed a per-day cost of $630 in a hospital outpatient setting. These factors will have an impact on increased use of and equitable access to both diagnostic and therapeutic radiopharmaceuticals.

The therapeutic success of Lutathera, approved in 2018, and Pluvicto, approved in 2022, is merely a snapshot of what’s to come. Pluvicto also received a label expansion in 2025 for use in an earlier line of therapy, and utilization trends for this drug have doubled over the last year.

The radiopharmaceutical market is projected to double by 2033 to more than $5 billion. With oncology as the top spending category and per member, per month driver among commercial, Medicare, and Medicaid lines of business, health plans have shown interest in oversight of these treatments as a part of drug therapy programs. As some therapies may cost $300,000 per course, the key is to ensure appropriate use and control spend, but there’s an opportunity to design drug therapy programs that feature responsible, timely prior authorization to protect patient safety.  As an industry, our attention needs to shift to responsible management of radiopharmaceuticals to help manage access and affordability

Lipid-lowering drugs will make waves

Will the maximum fair price and most favored nation drug pricing programs have a significant effect on Medicare and Medicaid costs? Not in 2026. But longer term, yes. The ripple effect of these programs across the industry will shrink the price differences between the U.S. and other nations when we look back five years from now.

As far as therapeutic areas are concerned, keep an eye on lipid-lowering drugs. Since the heydays of statins and PCSK9 inhibitors, the lipid-lowering class has been quiet. Starting in 2026 and beyond, the pipeline for lipid-lowering therapies is strong, and that is going to change. Another area to watch is biomarkers for precision medicine. Over the past five years, more than a third of all the new drugs approved by the FDA have biomarkers to guide therapy or diagnosis. This trend will continue in 2026 and have an even larger impact in the future. Payers and pharmacy benefit managers will need to dedicate more resources to monitor the use and cost of precision medicine and biomarkers.

Lastly, I think 2026 is going to be a turning point for biosimilars. Since it approved the first biosimilar in 2015, the FDA has required comparative efficacy studies for approval and interchangeability designation for substitution.  Both requirements will likely be removed in 2026, paving the way for lower cost and greater biosimilar adoption.

Drug pricing, other pressures will mount, creating an opening for outcomes-based pricing

In 2026, drug pricing debates will intensify as double-digit healthcare cost increases continue to squeeze employers and individuals. States will confront major Medicaid budget pressures, forcing difficult choices on coverage, supplemental rebates and formulary design. Consumer demand will keep rising, especially for GLP-1s, as prices begin to fall following federal negotiations and increased competition. Meanwhile, use of value-based assessments like ICER’s [Institute for Clinical and Economic Review] will expand as policymakers and payers push for tighter links between reimbursement and evidence of value. There is an opportunity for these pressures to move the system toward more transparent, outcomes-driven pricing models, though not without continued political and operational friction.

Innovation will simplify the healthcare experience

In 2026, expect continued innovation to simplify the healthcare experience and improve affordability. Consumers and employers alike are demanding a more sustainable, straightforward and personalized experience navigating a complex health care system. We’ve heard this feedback firsthand, particularly after we recently announced a new pharmacy benefit model designed to deliver greater transparency and lower costs at the pharmacy counter.

‘Rebate-free' will not change traditional PBM economics

In 2026, a broader push toward ‘transparent’ or ‘rebate-free’ models will be exposed as cosmetic changes, with the largest PBMs still running the same shell game simply under new labels. Once plan sponsors can look more closely at how these newly marketed models actually work, they’ll see that the underlying economics haven’t changed; dollars are just being redirected into less visible parts of the supply chain to keep PBM margins intact, exactly as they’ve signaled to Wall Street in their statements. Their incentive toward shareholder returns remains the same; only their terminology has shifted. As that becomes known, more plan sponsors will start pressing for visibility beyond transparent drug prices and questioning why their costs continue to rise.”

PBM pricing will fundamentally change

The PBM pricing landscape is undergoing a fundamental transformation. PBMs are evolving their pharmacy contracting strategies, introducing new approaches that move away from traditional average wholesale price-based discounts. These models are shifting how network pricing is structured and guaranteed to payers, emphasizing greater transparency and alignment with actual acquisition costs. At the same time, the deflation of manufacturer rebates is changing the way PBMs approach rebate guarantees. With rebate values under pressure, PBMs are shifting from per-brand structures to more durable, drug-level guarantees. Additionally, some arrangements now give payers greater access to rebate group purchasing organization revenue, increasing transparency and value. Legislative scrutiny and market disrupters are accelerating these changes, pushing PBMs to innovate in how they quote and deliver value to clients. As these trends converge, expect PBMs to offer more customized contracting solutions, greater clarity in pricing methodologies, and an emphasis on aligning incentives across the supply chain. The result will be a PBM market that’s more dynamic, accountable, and responsive to the evolving needs of payers and plan sponsors.

Payers will take charge and disaggregate traditional PBM functions

The waiting is over for federal and state regulators to decouple pharmacy benefit management services. 2026 will mark a clear pivot as health plans and large employers take matters into their own hands and disaggregate traditional PBM functions. Frustration with opaque economics, accelerating drug costs, and poor health outcomes is driving payers to unbundle claims processing, formulary management, mail order, and specialty services to gain control over cost and member experience. Continued scrutiny on traditional PBMs will add momentum, but the real accelerant is the rise of best-in-class point solutions that deliver transparency and measurable value. As employers rebuild their pharmacy strategies piece by piece, patients will experience more choice, clearer pricing and genuinely personalized care.