The pharmacy benefit management (PBM) industry is in the middle of a real shift, and it is one worth paying attention to as we head deeper into 2026. For years, the traditional PBM model worked largely behind the scenes: PBMs negotiated rebates with drug manufacturers, managed formularies and processed claims, while plan sponsors relied on those arrangements to manage pharmacy costs.
That framework is being more actively examined as concerns around transparency, affordability and market concentration continue to grow. With nearly 80% of the U.S. market controlled by just three players – Express Scripts, OptumRx and CVS Caremark – concerns over drug affordability and patient access are mounting. PBMs have become a focal point for lawmakers, employers, patient advocates and independent pharmacies, who are calling for greater insight into pricing practices.
The Rise of Cash-Pay and Direct-to-Consumer Options
One of the more notable developments over the past year is the growing appeal of cash-pay models. Direct-to-consumer, cash-pay options are gaining popularity among patients, some of whom are choosing to bypass insurance altogether in favor of lower out-of-pocket prices and simpler purchasing experiences, and these models are attracting attention from employers and payors frustrated with the complexity of established PBMs.
For certain generic medications, especially, the cash price at a discount pharmacy or through a program like Cost Plus Drugs Co. may be lower than a member’s insured out-of-pocket cost, highlighting variability in benefit outcomes.
On the GLP-1 front specifically, direct-to-consumer platforms have expanded access to medications such as semaglutide through manufacturer-affiliated cash-pay programs. As GLP-1 utilization moves from specialty curiosity to mainstream benefit line item, pricing dynamics around them are increasingly becoming a more prominent consideration for plan sponsors.
