Payer Preference Shifts Toward Unbundled, Transparent PBM Models

In a welcomed trend for the pharmacy industry, recent survey data from the Pharmaceutical Strategies Group (PSG) show that payers in the pharmacy benefits space are moving away from traditional, opaque pharmacy benefit management structures toward models that offer greater transparency and control.¹

“The core value proposition is one of transparency and control,” Jared Tate, PharmD, vice president of health plan consulting at PSG, said during a webinar presentation of the survey data.² “It’s not for everybody, but more and more of our health plans and employers want to really become the center of their pharmacy universe. They want to be able to adapt to the changing market without some of this cross-subsidization across the different parts of the supply chain.”

This shift is characterized by the rise of unbundled pharmacy benefit manager (PBM) service models, where core functions such as claims adjudication, pharmacy network management, and specialty drug management are contracted separately rather than through a single vendor.^1,2

READ MORE: Specialty Drug Costs and Complexity Steadily Rising Since 2025

PSG’s 2026 Trends in Drug Benefit Design Report revealed that awareness of this approach is surging, particularly among health plans, where 49% of respondents report having heard “a lot” about it, up from 40% in 2025. The perceived value of these arrangements is also climbing, with health plans rating the potential value at 6.8 and employers at 6.6 on a 10-point scale.¹

For pharmacists, the transition toward transparency addresses the black box model of legacy PBMs that has long obscured the true cost of medications. Traditional models often rely on opaque practices like spread pricing, where a PBM bills a client more than it pays the pharmacy, and the retention of an unknown percentage of manufacturer rebates.^3,4

In contrast, transparent and modern PBMs are increasingly adopting pass-through pricing models, where 100% of negotiated discounts and rebates are passed directly back to the plan sponsor, often in exchange for a simple, flat administrative fee. This alignment of incentives means PBMs are no longer motivated to steer patients toward higher-cost brand-name drugs simply to capture larger rebates.

The movement is even forcing the industry’s largest players to adapt.

UnitedHealth’s Optum Rx recently announced shifts in its model to push for greater transparency in response to these evolving market demands. This evolution is further supported by the industry’s shift toward value-based care, where PBM strategies are beginning to prioritize long-term patient outcomes over net costs.^5,6

Experts predict that PBMs will eventually follow the lead of hospitals and payers by publishing their contract rates, fostering a more informed discussion about who is being paid what along the supply chain. This shift is particularly relevant to pharmacists, as new models may focus on quality measures such as A_1c control for diabetic patients or ensuring patients receive necessary blood pressure screenings, rather than merely checking if a patient is on the cheapest possible medication, according to The Center for Biosimilars.⁶

Despite the clear appetite for change, the move toward full unbundling remains a complex undertaking. Although 44% of employers and 49% of health plans indicate they would pursue a partially unbundled approach in their next procurement, very few feel ready to go fully modular.¹

The challenges identified by survey respondents include the complexity of managing multiple vendors, the risk of gaps in the member experience, and the significant administrative burden of integrating disparate vendor systems.^1,2

Furthermore, a significant tension exists between risk and control. As webinar experts noted, while transparency provides the knowledge needed to audit and monitor effectively, it does not guarantee savings unless the payer is willing to make difficult coverage decisions.²

According to Navitus Health Solutions, as specialty drugs continue to drive over 50% of net drug spend despite representing only 2% of volume, the pressure for clarity will only intensify. With transparent PBMs already reporting significantly higher satisfaction ratings than traditional models, the data suggests that 2026 may be the tipping point for a PBM landscape that finally prioritizes accountability and clinical efficacy over hidden middleman interests.⁴

“Tension means trade-offs, and the trade-offs for each plan sponsor or health plan have to align with the capabilities and strategy. It’s not just a binary tension, but it’s strategic,” concluded Tate during the webinar.² “Plans have to choose the right balance based on their internal capabilities, their risk tolerance, their desire for market differentiation, and accept the fact that more control does mean more responsibility and variability.”

READ MORE: Transparent Cost-Plus Pricing Protects Pharmacies From Reimbursement Uncertainty

REFERENCES

1. Lee M, Lonergan M, Gregg R, et al. 2026 trends in drug benefit design report. Pharmaceutical Strategies Group. 2026. https://www.psgconsults.com/industry-report/2025-trends-in-drug-benefit-design-report/

2. Van Ginkel J, Tate J, Lee M, et al. 2026 trends in drug benefit design report webinar. Pharmaceutical Strategies Group. Presented virtually on: June 9, 2026. Accessed June 10, 2026. https://www.psgconsults.com/webinar/2026-trends-in-drug-benefit-design-report-webinar/

3. What is a transparent PBM and why it matters more than ever. SmithRx. February 19, 2026. Accessed June 10, 2026. https://smithrx.com/blog/what-is-a-transparent-pbm

4. Pharmacy benefit management by the numbers: 2026 and the cost of opacity. Navitus Health Solutions. January 26, 2026. Accessed June 10, 2026. https://navitus.com/pbm-101/pharmacy-benefits/pharmacy-benefit-management-by-the-numbers-2026-and-the-cost-of-opacity/

5. Tozzi J. UnitedHealth’s Optum Rx to shift PBM model in transparency push. Modern Healthcare. May 11, 2026. Accessed June 10, 2026. https://www.modernhealthcare.com/insurance/mh-unitedhealth-optum-rx-pbm-model/

6. Santoro C. PBM evolution toward value-based care shifts to transparent pharmacy pricing. The Center for Biosimilars. March 30, 2025. Accessed June 10, 2026. https://www.centerforbiosimilars.com/view/pbm-evolution-towards-value-based-care-shifts-to-transparent-pharmacy-pricing