New prescription drug transparency requirements that take effect during the next few years are giving employers more visibility into how prescription drug pricing works.
For business leaders who manage pharmacy benefits, this is a meaningful shift. But more data doesn’t automatically mean more clarity.
“Employers may get access to data they’ve never had before,” said Gary Petruzzelli, Vice President of Pharmacy Strategy and Services at Capital Blue Cross. “The challenge now is knowing what to do with it.”
Pharmacy pricing is still complex, and the rules are changing quickly. Employers will be in a position where they can see more – but turning that information into better decisions isn’t always straightforward.
Here are four important pharmacy trends and how to make sense of what they mean for your organization.
1. CAA 2026: You can see more of the system – but it’s still complicated
The 2026 Consolidated Appropriations Act (CAA) is expected to introduce new transparency requirements for pharmacy benefit managers (PBMs) by the end of 2028.
Once implemented, the law is intended to provide employers with broader insight into how pharmacy benefits are structured and how costs flow through the system. In practice, this will likely function as a higher-level “receipt” for pharmacy benefit activity – offering more visibility, but still requiring careful interpretation.
Pharmacy costs will still be driven by things employers don’t control, like drug companies setting prices. Think of it like your electric bill: you may be able to see a break-down of the charges, but you still don’t control the price of electricity.
2. AMP Cap: May help shift away from ‘high price, high rebate’ model
If the 2026 CAA may offer broader insights into how pharmacy benefits are structured, the removal of a cap on the Average Manufacturer Price – or AMP Cap – could reduce how much drug rebate money exists.
The American Rescue Plan Act, passed in 2021, eliminated the Medicaid AMP rebate cap effective Jan. 1, 2024. Previously, Medicaid rebates were capped at 100% of a drug’s price – so once that threshold was reached, manufacturers faced no additional penalty for raising prices.
With the cap removed, that dynamic could flip, as manufacturers would owe rebates exceeding a drug’s price if it had a history of large increases.
Although this policy change applies specifically to Medicaid, it has implications for the broader market. Changes to rebate requirements can affect drug pricing and costs across all lines of business, including employer-sponsored health plans.
“We’re starting to see a shift away from the traditional ‘high list price, high rebate’ model,” Petruzzelli said. “That model has defined pharmacy pricing for years, and policy changes like this are beginning to disrupt it.”
Self-funded commercial groups may start noticing that shift. While that may produce lower upfront costs at the point of claim, it may also mean smaller rebates, Petruzzelli said. It’s also important to remember that the cost of pharmacy benefits is rising across the country.
3. GLP-1s: Lower prices don’t always mean lower costs
GLP-1 medications (like Ozempic and Wegovy) highlight how quickly the market is evolving – but not always in ways that directly translate into employer savings.
Government negotiations under the Inflation Reduction Act (IRA) are expected to significantly reduce prices for some of these drugs – by roughly 70% in Medicare starting in 2027. While those changes are specific to Medicare, they’re already influencing broader market dynamics.
“As list prices come down, the rebates tied to those drugs tend to come down as well,” Petruzzelli said. “For many self-funded employers, that shift often balances out net costs.”
In other words, while rebate checks may be smaller, the underlying cost of the drug is also lower – often resulting in a net effect that’s close to neutral.
And if prices drop, utilization is likely to rise. Expanded access can make these medications available to more employees, which can ultimately increase overall pharmacy expenses – unless employers address it through thoughtful plan design.
4. AFPs: Some ‘savings’ strategies come with trade-offs
Alternative Funding Programs (AFPs) aim to lower costs by carving out certain specialty drugs and healthcare services from coverage and directing members to outside funding sources, such as manufacturer assistance programs. It can also include things like international sourcing of drugs.
But research shows this approach can backfire. Members may face delays, may not qualify for assistance, or may be left responsible for the full cost of their medication. Studies suggest these delays can average around two months and may even worsen health outcomes – ultimately increasing the cost of care and decreasing the quality of outcomes.
Some strategies can look like savings at first – but create new problems later.
For example, an employer may carve out a high-cost drug expecting savings. But if an employee can’t qualify for outside funding, they may suddenly lose access to their medication.
What looked like a cost-saving move can turn into an employee experience issue, added complexity, and potential risk for the organization.
How Capital Blue Cross can help
Pharmacy benefits are becoming more complex and more difficult to manage.
That also means more decisions, more trade-offs, and more complexity to navigate.
Capital Blue Cross helps employers make sense of what they’re seeing – turning complex data and changing pharmacy benefit economics into clear, practical decisions about plan design, cost management, and employee experience.
Because in today’s environment, success isn’t just about having more data. It’s about turning that data into clarity – and using it to make better choices.