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Yet another year ends. Check out our 2025 recap and insights on what might be in store for 2026.
Trend
Trend in 2025 will end higher than 2024 for most, with overall industry trend expected around 15%, before rebates. Compared to last year, rebates are having a greater impact on mitigating trend, with an anticipated offset of about 2%. National CooperativeRx’s trend before rebates is expected to outperform industry benchmarks again, at approximately 11%. Looking ahead to 2026, trend is likely going to be similar, but with a lower offset of trend by rebates.
Trend Drivers
Trend and spend for specialty drugs trails behind non-specialty. Newer-to-market specialty brands, especially dermatologicals, continue to pick up market share as products receive additional FDA-approved indications. Evolving biosimilar markets continue to mitigate trend. Biosimilar uptake is occurring more rapidly with Stelara compared to Humira, even without pharmacy benefit managers (PBMs), like CVS Caremark, deploying a formulary exclusion strategy for the reference brand. As of November, biosimilars have already captured about 40% of the Stelara market share by claims for National CooperativeRx member-owner groups.
Non-specialty trend continues to be driven primarily by GLP-1s, with growing demand from expanded FDA-approved indications, including Wegovy for MASH. Other diabetes products, including SGLT2 inhibitors, continuous glucose monitors, and disposable insulin pumps, have contributed, but to a lesser extent. Demand also remains strong for newer migraine therapies like Nurtec and Qulipta and Rezdiffra for MASH.
In the case of preventable diseases, low and declining vaccination rates are being seen along with outbreaks of contagious diseases such as measles. Cost increases continue to grow for the treatment and symptomatic care of COVID, flu, and pneumonia.
Pipeline
Several firsts are expected in 2026, including an under-the-tongue epinephrine for severe allergic reactions (anaphylaxis) and a combination COVID/flu vaccine.
Cancer remains the greatest area of focus for research and development, with cardiovascular and metabolic disease close behind.
There are more than 100 GLP-1 products in the pipeline by 50+ companies, with NovoNordisk and Lilly likely to dominate the market, at least in the near term. Oral Wegovy is expected to be reviewed by the FDA before year’s end, while high-dose injectable Wegovy is expected in 2026. Lilly’s orforglipron (another oral GLP-1) is close behind. Other next-generation products are also in development, including combination products and products with multiple mechanisms of action, all aimed at more effective and better-tolerated therapies. Expect renewed interest in weight loss GLP-1s as new products make their way to market.
PBMs
Many contract holders were taken by surprise when some PBMs exercised rebate adjustments in 2025. Market events such as a drug maker bankruptcy, ACA coverage mandates, and unexpected utilization trends were cited as compromising rebate invoicing opportunities relative to guarantees, thus prompting the adjustments. The impact was felt more strongly by some than others. The true impact to the bottom line may not be seen until 2026 due to the delay in rebate payments and the timing of adjustments.
Rebate credits and associated methodologies are alive and well. These may vary by PBM and from one contract to another. More products will see industry-wide list price reductions at the start of 2026. That’s right! More list reductions, more rebate credits, and potentially more already over-inflated guarantees on spreadsheets. Some brokers, consultants, PBMs, and coalitions are better about quantifying this than others. These dynamics, along with others, like fiduciary responsibilities, contributed to a very active 2025 RFP season. Expect activity to continue in 2026 and 2027.
A transition towards greater transparency gains steam with rebates. A push towards drug-level rebates is underway. This helps PBMs mitigate underwriting risk and provides the transparency many are asking for. This will complicate repricing comparisons given the differences in formulary and preferred brand strategies from one PBM to the next. In recent years, PBM efforts have worked to better align contract terms and move away from cross-subsidization between channels, allowing retail, mail, and specialty discounts to stand individually.
As more direct-to-consumer offerings take hold, such as NovoCare and Lilly Direct, as well as clearinghouse platforms like TrumpRx and AmericasMedicines, PBMs may see increased pressure to accommodate or counter these offerings with competitive alternative(s).
Reform
State legislation remains active and touches just about all aspects of the pharmacy benefit. Several states have enacted PBM legislation that limits the ability to administer cost-saving prescription benefit programs for clients. All 50 states have passed some version of PBM reform. These reforms vary greatly, from basic state licensure of PBMs to expansive limits on the PBMs’ ability to operate utilization and cost savings programs for plan sponsors. ERISA protections are sending several state reforms through the court system and so far, ERISA protected plan sponsors have prevailed. More challenges to state-passed legislation are expected.
Consolidation
Major pharmacy chains like CVS and Walgreens continue to consolidate to fit market demand. While there is no exact count of cash-pay-only pharmacies, industry reports suggest steady increases, especially among independent and online pharmacies. More cash-pay-only or direct-to-consumer pharmacies may mean fewer PBM pharmacy network providers and more pharmacy deserts.
Walgreens Boots Alliance went private in August 2025 after acquisition by Sycamore Partners. Five standalone companies are now operated; Walgreens, The Boots Group, Shields Health Solutions, CareCentrix, and VillageMD.
Smaller drug makers with promising products in the pipeline continue to get acquired by larger ones. Metsera’s GLP-1 resulted in a bidding war between Pfizer and Novo Nordisk. Pfizer ended up paying about $10B for Metsera. Less competition may mean higher costs for consumers in the long run.
Alternative Funding and Sourcing
Those exploring these options may find it harder to achieve savings, even as vendors expand offerings such as needs-based, non-needs-based, and international sourcing. Question savings methodologies. Savings from these continue to dry up and fall short of expectations due to changes being seen in patient assistance and other aspects in the marketplace.
Patient Assistance
Drug makers continue to tighten eligibility requirements. Non-needs based or copay card programs continue to see lower amounts of value offered and covered by drug makers. Copay maximizer programs may disqualify patients for eligibility. Needs-based programs are not as generous. Many drug makers have their financial eligibility thresholds from 600% to 400% of the Federal Poverty Level, with some drug makers considering 200% for 2026 and beyond. Insurance coverage of any sort may disqualify folks from eligibility. Pharma appears to be preparing to weather a storm; a surge of uninsured, underinsured, and commercially insured who may leverage these programs.
Employer-Sponsored Insurance Plans
Commercial plan sponsors may see an influx of participants to their plans as spouses and dependents covered elsewhere may seek alternative options. Healthcare Exchanges may become unaffordable for many individuals as ACA premium’s rise and subsidies are not renewed. In addition, millions are expected to lose Medicaid coverage in 2026 and 2027.
National CooperativeRx is here to help plan sponsors, employee benefits brokers, and PBM consultants navigate the pharmacy benefit industry. Our team of experts are a resource and advocate on your behalf. By utilizing National CooperativeRx as a trusted advisor, you can feel confident in your pharmacy benefit decisions. If you are interested in discussing how changes in the industry may affect your pharmacy benefit plan, please reach out to your National CooperativeRx account representative.
