Pharmacy costs are spiraling out of control, and traditional solutions aren’t working. Prescription drug spending increased 11.4% in 2024, with net prices reaching $487 billion, led by high-cost GLP-1s and specialty drugs. And total spending on prescriptions is expected to grow by $116 billion in 2029, compared to 2024, exceeding $600 billion. Specialty medications already account for 54% of all drug spending, with many more high-cost drugs in development and GLP-1s continue to dominate the top 10 drugs, driving utilization and therefore trend.

As the pharmacy benefits landscape evolves, HR teams face an important question: Is their current plan meeting their needs? Whether you work with a large traditional pharmacy benefit manager (PBM), a regional organization or a so-called transparent pharmacy benefits provider, here are some key considerations:

• Are your benefits provider’s incentives and success metrics aligned with yours?
• Is the clinical management, including plan design and formulary options, delivering on your cost savings and member care goals?
• Are you armed with the plan-specific data and actionable insights that make your benefits sustainable for the long term?

If not, it’s time to reevaluate. You need a partner who cuts through the smoke and mirrors to deliver benefits plan options that meet you where your organization is and deliver on your goals, be they savings or employee outcomes.

As a pharmacy benefits optimization (PBO), RxBenefits has a 30-year legacy in delivering pharmacy benefits options that deliver savings HR teams can rely on with a relentless focus on delivering superior member care and outcomes.

Here are four ways a PBO model helps you optimize your plan design and performance for results – today and in the future:

1. Aligned model with no financial conflicts

The PBO model differs from traditional PBMs in that it aligns with your company's goals. As a PBO, RxBenefits maintains a curated marketplace of pharmacy benefits and specialty cost containment solutions so you can handpick the options that match your plan’s unique needs.

You make informed choices based on expert insights powered by your plan’s actual demographic and utilization data – not generic benchmarks – that reveal hidden savings opportunities.

Unlike traditional PBM models, RxBenefits doesn’t benefit from tactics that conflict with your plan’s financial goals, such as spread pricing, rebate withholds or requiring the use of owned specialty pharmacies.

The bottom line: For financially aligned advocacy, strategic flexibility and guaranteed, verifiable results, consider a PBO.

2. Clinical utilization management

From ensuring that clinically equivalent, lowest-cost drugs are prioritized on formularies rather than those with high manufacturer incentives, to removing high-cost therapies that do not provide an incremental benefit, targeted clinical management strategies can balance plan sustainability with member access.

Automated, algorithm-governed prior authorization (PA) reviews either hurt members by simply denying treatments or allow inappropriate and off-label prescriptions, resulting in waste and higher costs for the employer. Your pharmacy benefits plan should work for your members, not against them. Clinical management begins with formulary optimization – ensuring the most cost-effective drugs are prioritized. And human-led PA reviews ensure your plan delivers the right medications to the right person at the right dose by directing them to lower cost alternatives.

A PBO model achieves the lowest net cost while minimizing member disruption and protecting access to vital medication.

The bottom line: The right clinical management strategies mean your formulary is optimized to meet budget and savings goals while delivering lower disruption and better member outcomes.

3. High-touch, targeted support for specialty and complex conditions

Here's a staggering stat: specialty drugs represent 51% of a typical plan's total drug spending, despite accounting for only 2% of all prescriptions. These members are often on complex medication regimens and, therefore, at risk of adverse events. That’s why your highest-cost members need specialized attention.

As a PBO, RxBenefits offers high-touch intervention through personal interactions with patients and collaboration with disease-specific specialists to optimize medication therapies. Independent clinical pharmacists address critical cost drivers, including:

• Biosimilar interchange opportunities: Identifying clinically effective, lower-cost alternatives
• Dosing errors: Correcting inappropriate dosing that causes waste and safety concerns
• Therapy optimization: Ensuring appropriate medications for each patient's condition

These personalized interventions go beyond automated reviews. Clinical pharmacists understand patient needs and work to optimize outcomes while identifying opportunities to lower costs.

The bottom line: Greater, personalized support for members with complex, chronic conditions benefits them, as well as the plan.

4. Cost management strategies for emerging trends

Effectively managing today’s pharmacy landscape can help employers control costs. But to ensure long-term sustainability, employers need a partner with an eye to emerging trends and future developments.

GLP-1 drugs are a perfect illustration of this. Originally approved for Type 2 diabetes, these medications are highly effective for weight loss, which has created a utilization explosion. Nearly two million GLP-1 prescriptions were filled in December 2024, four times the number in December 2023. And RxBenefits’ analysis shows that without appropriate management, up to 40% of prescriptions are outside plan design. RxBenefits implemented a review specifically for GLP-1 drugs, which delivered $52 million in client savings in 2024.

GLP-1s represent just the latest cost pressure. Psoriasis and other dermatological treatments are poised to follow a similar trajectory. No longer the realm of topical or over-the-counter treatments, now a variety of top-dollar treatments cost hundreds of thousands of dollars annually. And, the pharmaceutical pipeline suggests this pattern will repeat across therapeutic areas. Oncology, immunology and rare disease treatments continue advancing, creating new high-cost scenarios.

RxBenefits’ experts provide optimization recommendations based not just on current market trends but emerging ones to help your plan always stay ahead.

The bottom line: To ensure plan success today and tomorrow, you need a partner who can anticipate new cost pressures, not just react to them.

Taking action on your pharmacy benefits

The pharmacy benefits landscape changes rapidly and standing still means falling behind on cost management. And, your employees deserve benefits plans that prioritize patient care over vendor profits. The PBO model offers a clear alternative to traditional PBMs, built on transparency, accountability and genuine alignment with your goals.

The question isn’t whether pharmacy costs will continue rising – it’s whether your current approach can handle what’s next. If you can’t confidently track your pharmacy dollars or verify that your plan serves your interests, it’s time to explore how a PBO partnership could transform your pharmacy benefits strategy.