9 pharmacy benefit management strategies for employers.

For self-funded employers, pharmacy benefits can no longer be managed through annual renewals alone. Drug spend is too complex, specialty medications are too costly and traditional pharmacy benefit management (PBM) pricing can make it difficult to understand what the plan is actually paying.

The strongest PBM strategies for employers focus on one goal: the lowest net cost with better member support. That means looking past rebate checks, headline discounts and broad network claims to understand how every part of the PBM model affects plan spend, employee access and long-term healthcare outcomes.

Key highlights:

• Pharmacy benefit management strategies are the actions employers use to manage drug pricing, formulary design, specialty utilization, reporting and member support.
• Transparent pricing matters because employers need to see how claims are priced, how rebates are handled and where PBM revenue is earned.
• Specialty drugs require focused cost control because a small share of medications can drive a large share of pharmacy spend.
• Rightway helps employers build a more accountable PBM strategy through transparent pricing, pharmacist-led navigation, clinical oversight and integrated care support.

Here are the top nine pharmacy benefit management strategies for employers.

1. Prioritize transparent pharmacy pricing.

Transparent pricing is the starting point for any effective PBM strategy. If an employer cannot see how a claim is priced, how rebates are passed through or how the PBM earns revenue, it becomes difficult to know whether the plan is reducing costs or funding hidden margin.

This matters even more in a concentrated PBM market. The Federal Trade Commission reported that the three largest PBMs processed nearly 80% of U.S. prescriptions in 2023, while the six largest processed more than 90%. For employers and consultants, that market concentration makes contract clarity and claims visibility essential.

Pricing transparency should make the economics of every claim easier to understand:

• Transparent pricing structures: Plan sponsors should know whether their PBM uses pass-through pricing or another revenue model, like spread pricing, to charge the plan more than it pays the pharmacy and keep the difference.
• Rebate pass-through visibility: Rebate value should be reported clearly and passed through according to the contract. Employers should be able to see which drugs generated rebates, when those rebates were paid and how they affected net cost.
• Claims-level reporting access: Employers need access to claim details such as NDC, ingredient cost, dispensing fee, plan paid amount, member cost share, channel, pharmacy and administrative fees. Summary-level reports are not enough.
• Fiduciary-aligned pricing models: A pricing model should reduce conflicts of interest. When PBM revenue is tied to a clear administrative fee instead of spread, retained rebates or steerage, it is easier to align the PBM with the employer’s cost goals.

2. Build a specialty medication cost control strategy.

Specialty medications are one of the biggest pressure points in pharmacy benefits. They often treat complex conditions, require careful clinical review and can carry significant plan costs.

That is why employers need pharmacy benefit management specialty medication cost control strategies that go beyond prior authorization. A stronger approach looks at utilization, site of care, biosimilars, clinical appropriateness and specialty pharmacy performance together.

Monitor specialty medication utilization.

Employers need clear visibility into which specialty medications are driving spend, which conditions are creating trend and whether members are filling through the right channel. A strong specialty pharmacy strategy should show more than total cost. It should help employers understand what is being used, why utilization is increasing and where clinical or network changes could reduce waste.

The most useful specialty utilization reviews should help employers identify:

• Specialty drugs account for the highest plan-paid amounts.
• Necessary dose increases or extended therapy duration that may need clinical review.
• Claims that are being billed through the pharmacy benefit versus the medical benefit.
• Members who need additional pharmacist support, provider coordination or adherence outreach.

Optimize site-of-care strategies.

The same specialty therapy can cost the plan very different amounts depending on where it is administered. Site-of-care reviews help employers determine whether members can receive the same clinically appropriate treatment in a lower-cost setting.

A strong site-of-care strategy should help employers:

• Identify specialty therapies with meaningful cost variation by setting.
• Compare hospital outpatient costs against physician office, infusion center, home infusion or pharmacy-based options.
• Protect members from unnecessary disruption during any transition.
• Track savings, member experience and therapy continuity after implementation.

Expand biosimilar adoption.

Biosimilars can lower specialty costs when they are clinically appropriate and supported by the right formulary, provider and member strategy. Employers should evaluate biosimilar opportunities based on total net cost, not list price alone.

A biosimilar strategy includes:

• Reviewing high-cost biologics with available biosimilar alternatives.
• Comparing net cost after rebates, discounts and plan-paid amounts.
• Evaluating formulary placement and prior authorization rules.
• Monitoring acceptance, disruption and savings after implementation.

Strengthen clinical oversight programs.

Strong clinical oversight helps confirm that high-cost therapies are clinically appropriate, dosed correctly and supported throughout treatment. This is especially important for specialty drugs that require ongoing monitoring or reauthorization.

Clinical oversight programs should include:

• Evidence-based prior authorization criteria.
• Step therapy when clinically appropriate.
• Reauthorization tied to response, diagnosis or continued clinical need.
• Pharmacist support for adherence, side effects and therapy changes.

Review specialty pharmacy network performance.

Specialty pharmacy network performance affects both cost and member experience. Employers should understand how pharmacies are selected, how quickly members receive medications and whether any PBM-owned or affiliated pharmacy relationships create conflicts.

A specialty pharmacy network review should answer the following:

• How often do members abandon therapy before the first fill?
• Can members reach support when they need help?
• Does drug-level pricing vary across network pharmacies?
• Do ownership or referral arrangements influence pharmacy selection?

3. Improve formulary management and optimization.

A drug formulary is the foundation of how a pharmacy benefit determines what members pay and what the plan covers. When built around clinical evidence and net cost, they create real savings and produce better member outcomes. Conversely, when they are designed around pharmaceutical rebate volume, employers and members often pay more for branded drugs that have lower-cost alternatives available.

Employers should review whether formulary decisions are based on clinical value, affordability and plan performance. The question is not just which drugs are covered. It is whether the program is designed to deliver the lowest reasonable net cost while supporting appropriate member access.

A well-managed formulary strategy includes:

• Evidence-based formulary design: Formulary tiers and coverage decisions should reflect clinical appropriateness and net cost, not manufacturer rebate size or PBM-preferred drug positioning.
• Generic medication utilization: Generic drug pricing offers a direct path to lower plan costs when it is properly prioritized. Employers should confirm that generic substitution policies are active, enforced and tracked against clinical appropriateness benchmarks.
• Preferred drug strategies: Preferred tier placement should guide members toward the most cost-effective, clinically appropriate options. Employers should understand how preferred drugs are selected and whether manufacturer relationships influence tier decisions.
• Exclusion management: Drug exclusion lists can reduce plan exposure to high-cost branded drugs with lower-cost equivalents. But poorly managed exclusions create access barriers. Employers should confirm that exclusion decisions are paired with viable alternatives and member communication.
• Ongoing formulary reviews: Drug pricing and clinical evidence change. Formularies should be reviewed at least annually to reflect new generics, biosimilar approvals, rebate changes and updated clinical guidelines.

4. Use data and reporting to monitor pharmacy trends.

Employers who manage pharmacy benefits effectively do not wait for renewal to understand their spend. They use ongoing reporting to track where costs are rising, which members need support and whether the PBM is delivering on contracted performance. Without consistent data access, it is difficult to act before small trends become expensive problems.

The most actionable pharmacy benefit reporting covers spend trends, utilization patterns, clinical outcomes and population health signals together. No single report tells the full story.

5. Improve member support and pharmacy navigation.

Effective pharmacy benefit management strategies for employers account for more than pricing. Member experience shapes how employees use their pharmacy benefit. When members cannot reach support, do not understand their options or abandon medications because of cost or confusion, the plan absorbs the downstream consequences.

Poor adherence is not just a clinical problem. It drives avoidable emergency visits, hospitalizations and total healthcare costs that employers ultimately fund.

Clinical guidance gives members direct access to support rather than routing them through a call center with limited expertise. When a pharmacist is involved in the member conversation, the direction is more specific, more accurate and more likely to result in the right decision for both the member and the plan.

Effective member support programs include:

• Pharmacist-led navigation: Care navigation helps members find lower-cost medications, understand their coverage, navigate prior authorizations and make informed decisions about their care without having to interpret complex benefit documentation on their own.
• Medication adherence support: Your program should identify members at risk of stopping therapy early, reach out proactively and address barriers including cost, side effects and access. Reactive support is not enough.
• Real-time member guidance: Members should be able to reach clinical support when they need it, not the next business day. Real-time guidance reduces errors, prevents unnecessary fills and helps members avoid costly coverage gaps.
• Proactive outreach programs: The strongest member support programs do not wait for members to call. They identify members who need help before a care gap opens, such as a missed refill and initiate outreach through the appropriate channel.

6. Align pharmacy and healthcare strategies.

Pharmacy benefits do not operate in isolation. The medications a member takes affect their clinical risk, their provider interactions and their total healthcare spending. When pharmacy and broader healthcare strategies are managed separately, employers lose visibility into the full cost picture and miss opportunities to coordinate support for members with the highest needs.

Here are five areas where tighter alignment between pharmacy and healthcare strategy drives better outcomes:

1. Improve healthcare data visibility.

Employers who integrate pharmacy and medical claims data have a clearer picture of how benefits interact. They can see whether a member managing a chronic condition is adherent to their therapy, whether that condition is driving downstream medical utilization and where earlier intervention could reduce total cost.

A stronger data strategy connects pharmacy to the broader healthcare picture, helping:

• Connect pharmacy and medical claims at the member level.
• Identify chronic condition populations with high total healthcare cost.
• Track whether pharmacy adherence correlates with medical utilization changes.
• Use integrated data to prioritize proactive clinical outreach.

2. Coordinate pharmacy and care navigation support.

When pharmacists and care navigation teams share member information, they can coordinate outreach and avoid duplicate or conflicting guidance. A member receiving support for a specialty medication should not have to explain their situation separately multiple times. Connected support models reduce friction and improve outcomes.

A coordinated support model should:

• Align pharmacist and navigator outreach for high-risk members.
• Share relevant clinical context across support functions.
• Coordinate transitions when a member's clinical needs change.
• Reduce the number of support contacts a member has to manage.

3. Create more connected member experiences.

Members who find their benefits confusing are less likely to use them effectively. Clear member benefits understanding and consistent navigation support help employees engage with the right care at the right time. A more connected experience also reduces the administrative burden on HR teams who would otherwise field questions directly.

Here are four practical steps toward a more connected member experience :

1. Simplify benefit explanations at enrollment and throughout the plan year.
2. Provide a single point of contact for pharmacy and healthcare questions.
3. Ensure member-facing communications are consistent across channels.
4. Track whether members who engage with support show better utilization patterns.

4. Align clinical and financial healthcare strategies.

Employers should not have to choose between clinical quality and cost control. A well-structured pharmacy benefit aligns by directing members toward clinically appropriate medications at the lowest reasonable net cost. That requires a PBM whose financial model is not in conflict with those goals.

Close the gap between clinical and financial goals by taking these four steps:

1. Confirm that formulary and network decisions are driven by net cost, not manufacturer relationships.
2. Evaluate whether PBM incentives align with plan savings or with vendor margin.
3. Set clinical program targets alongside financial performance goals.
4. Hold the PBM accountable to both in quarterly reporting.

5. Reduce fragmented healthcare experiences.

Fragmentation is one of the biggest contributors to unnecessary healthcare spending. When members navigate pharmacy, medical, behavioral health and care navigation through disconnected channels, they make less informed decisions and the plan absorbs higher costs. Employers who invest in connected benefit models see better outcomes and fewer avoidable claims.

Here’s how to reduce fragmented experiences for your employees:

• Identify where members experience the most friction across benefit channels.
• Evaluate whether pharmacy and medical benefits are administratively coordinated.
• Assess whether behavioral health and specialty medication support are aligned.
• Look for opportunities to consolidate navigation support under a unified model.

7. Regularly audit PBM performance.

A contract with a transparent PBM is the starting point, not the finish line. Employers should conduct regular audits to confirm that contracted terms are being honored, that rebates are flowing as promised and that performance metrics reflect actual plan results. Without ongoing oversight, even well-structured contracts can drift from what was agreed.

PBM audits reveal whether your vendor is delivering on its commitments.

8. Improve employee engagement with pharmacy benefits.

Employees who do not understand their pharmacy benefit make decisions based on habit, cost anxiety or convenience rather than clinical appropriateness. That leads to abandoned medications, inappropriate channel selection, avoidable emergency visits and higher total plan costs. Engagement is not a soft metric. It directly affects utilization patterns, adherence rates and the return on clinical programs the plan has invested in.

Better engagement starts with clearer communication. Employees should understand what their benefits cover, how to use them and where to go when they have questions.

Effective employee engagement strategies include:

• Benefit communication campaigns: Proactive, plain-language communication at enrollment, during open enrollment and throughout the year helps employees connect their benefit to their actual healthcare needs. Campaigns should address common confusion points, including prior authorization, specialty access and mail order savings.
• Digital member tools: Mobile apps, member portals and real-time cost comparison tools help employees make better decisions. The easier it is to check a price or find a lower-cost alternative, the more likely members are to use those options.
• Pharmacy savings education: Many employees do not know that the same medication can cost significantly different amounts depending on the channel, pharmacy or formulary tier. Targeted education about mail order savings, generic alternatives and copay assistance enrollment can reduce member out-of-pocket costs and drive more appropriate utilization.
• Member enrollment support: New plan members and newly eligible employees often need additional support to understand their pharmacy benefit and complete any required enrollment steps. Proactive outreach at onboarding reduces confusion and prevents early gaps in medication access.

9. Choose transparent PBM models that align with employer goals.

Evaluating a PBM is not just a contract exercise. It is a decision about which financial model will govern the employer's pharmacy spending for the next several years. The right partner should be able to demonstrate how it earns revenue, how it handles rebates, how it makes formulary decisions and how it will hold itself accountable to the employer's goals.

Transparency looks different across PBM models. Some offer more disclosure than traditional solutions without eliminating the revenue streams that create misalignment. Employers and consultants should evaluate whether a vendor's stated transparency extends to its financial structure, not just its reporting dashboards.

When comparing PBM partners, the most important evaluation criteria includes:

• Pass-through pricing models: The partner should charge the plan exactly what it pays the pharmacy — no spread, no markup, no retained difference — and pass through 100% of manufacturer rebates directly to the plan. Employers should confirm that both apply across all drug categories, including specialty and GLP-1 medications, not just standard retail claims.
• Claims and PBM rebate visibility: Rebate reporting should go beyond aggregate summaries. Employers should be able to see rebate amounts by drug, manufacturer and quarter, with documentation confirming 100% pass-through against contracted guarantees.
• Employer-aligned incentives: A vendor whose only revenue source is a flat administrative fee has no financial interest in higher drug prices, preferred manufacturer arrangements or steerage toward high-cost channels. That structure is meaningfully different from a model where PBM revenue grows as plan spend grows.
• Pharmacist-led clinical support: Pharmacy benefit managers that connect staff members with pharmacists rather than general representatives can catch prior authorization errors, identify lower-cost alternatives and ensure adherence more effectively.
• Long-term healthcare accountability: The strongest partnerships include contractual performance guarantees, not just intent. A proactive healthcare strategy should be backed by measurable commitments to savings targets, rebate pass-through, claims accuracy and clinical program outcomes that employers can audit and verify.

Improve your PBM strategy with Rightway.

As a fiduciary-aligned, fully transparent PBM, Rightway passes through 100% of rebates, charges zero spread on any claim and earns a single flat administrative fee as its only revenue source. The clinical team is composed entirely of pharmacists and pharmacy technicians, which means members receive guidance from people qualified to give it.

For employers managing complex pharmacy spend, Rightway combines aligned pricing, pharmacist-led navigation, proactive clinical strategies and integrated care support into a single accountable model.

Book a demo today and explore how Rightway enhances pharmacy benefit management strategies for employers.