2026 Outlook: Plenty of Industry Changes

National CooperativeRx is steadfast in navigating pharmacy complexities with the best interest of patients and our membership at the center of every decision. The pharmacy benefit landscape remains very active. New trend drivers, changing list prices and rebate dynamics, state and federal reform, and shifting PBM approaches are making for uncertain times. Being engaged and working with trusted partners is as important as ever to navigate these changing dynamics.

Higher Pharmacy Trend

The prescription drug market is once again contributing to healthcare trend at a higher pace. Trend took another step up in 2025, expecting to reach 15% over 2024. National CooperativeRx continues to beat industry trend by helping members implement solutions to drive waste from plan spend.

As always, National CooperativeRx is on watch and will navigate in our members’ best interests. We continue to control waste in areas like dermatological products, promote Stelara biosimilar adoption, put controls in place to supplement PBM approaches, and are investigating additional GLP-1 management options to help control cost increases. All of our existing industry-leading oversight activities continue in 2026.

Federal Reform

Federal reforms to pharmaceutical pricing have suddenly become very active. The Biden administration policies seeking to rein in high prescription drug prices go into effect in 2026 and are continued under the Trump administration. In addition, President Trump’s most-favored-nation policy and direct-to-consumer drug plans were introduced and are progressing rapidly.

While there are questions as to the impact of these policies, they largely impact Medicare and Medicaid and help uninsured or underinsured patients. National CooperativeRx will continue to monitor developments and keep members and partners informed when developments warrant.

Rebate Changes

Rebate changes began with lower list prices and reduced rebate values for insulins, as well as lower list prices and rebate values among biosimilar competitors to Humira, the top-selling drug by revenue. While the significant rebate value of GLP-1s prop up rebate value, regulatory changes, utilization shifts, and other market factors are forcing PBMs and pharmaceutical companies to adjust rebate dynamics. At the Cooperative, we are tracking 2025 adjustments from CVS Caremark and how these, and other changes, will impact 2026. In addition, we are tracking rebate changes across industry coalitions and with other PBMs. We expect to present alternatives for our members in 2026.

Membership Expansion

For the first time in our over 20-year history, National CooperativeRx not only eclipsed 500,000 patient lives, we blew through it. In 2025, 71 new members joined the Cooperative, bringing an expected count of over 125,000 new lives. We anticipate the Cooperative to approach 550,000 total lives when the final numbers come in. Our growth delivers purchasing power and resources to expand our offerings.

This growth is driven by plan sponsors shopping PBM services at record levels. National CooperativeRx is poised to offer these plan sponsors the independent, expert solution they need. The Cooperative saw 373 opportunities in 2025, compared to a five-year average of 199. This trend of employers reassessing their PBMs is expected to continue in 2026.

NCRx Engagement Push and Service Enhancements

Cooperatives by structure are a collection of engaged individuals or entities with common interests working together for a better outcome. After years of expansion in size and reach, we are starting to see negative impacts of lower engagement across Cooperative membership. Engagement leads to lower spend and higher-value care for patients. In 2026, we have a renewed focus to engage with members on plan spend, management options, and industry complexities. Not only have we added to the National CooperativeRx team, but CVS Caremark is set to provide a greater level of support to our membership in 2026.

Announcement of 2nd PBM Option

While a formal announcement is premature, we expect to have a second PBM option in early 2026. CVS Caremark has been a valued PBM solution for most of our existence. With growing industry complexities, the Cooperative has been on a multi-year search for another solution to match the needs of members and prospects. We believe now is the time. We expect this solution to provide Cooperative members with a pass-through pricing option outside the Big 3 PBMs, as well as greater flexibility. Plan sponsors willing to accept the associated disruptions will also benefit from greater spend management.

Audit Returns

A core function of National CooperativeRx is holding the PBM accountable for the significant contract value they have agreed to. Often, audit returns are low. This is preferable as discounts were delivered on time. Recently, we have seen much more significant audit returns and it has delayed recoveries. In 2025, we returned $6.6 million to members for 2021 and 2022 audit years. With the support of our independent consultant and CVS Caremark, we are getting 2023 and 2024 wrapped up and we will start 2025 on time. We are tracking over $22 million to be paid out to members early in 2026 as we close the 2023 and 2024 audits.

Financial Strength

The Cooperative’s strong financial performance continued in 2025, and as a result, we are again expecting a significant membership dividend. With various returns and recoveries all passed through to membership, we expect to book net income of roughly $3 million for 2025. Our solid financial position continues to allow for early equity retirement and investments that add additional value for our members.

National CooperativeRx was founded to bring purchasing power and expertise to pharmacy benefits management. Everything we do is with our members’ best interests in mind. The Cooperative is in a strong position to navigate this ever-changing marketplace. We stand ready to help our members and partners provide a solution focused on the fiduciary obligations of plan sponsors. Thank you for being a part of the National CooperativeRx community as we continue to navigate the complexities of the prescription drug marketplace.