Transcarent

Jonathan Koval

Medication Strategy Leader

Turning Pharmacy into a Strategic Benefits Lever

For many employers, pharmacy is one of the fastest-growing parts of the health care budget. Industry surveys now project prescription drug costs to climb as much as 11% this year, the fastest pace of any benefit category, and pharmacy now represents more than a quarter of large-employer health spending, up from about a fifth a few years ago. It is also one of the most opaque line items: specialty drugs drive much of this growth, PBM contracts often make costs difficult to track, and employees still reach the pharmacy counter without knowing what they will pay.

Employers have tried to address this through contracting and benefit design, but those efforts alone do not solve the problem. A prescription often signals a new diagnosis, a change in treatment or the need for more support, yet many benefit strategies separate pharmacy from the rest of the health and care journey. Pharmacy is also the most frequent touchpoint a member has with their benefits, by a wide margin over medical, which is precisely why it can serve as the foundation of the strategy rather than a downstream cost to manage. Employers get more value when they connect these pieces.

Using Prescriptions as Signals for Earlier Intervention

A new prescription gives useful information about what a member needs next, and can be used to intervene earlier, improve outcomes, and lower costs. Consider an employee who receives a GLP-1 prescription: acting on that signal early means guidance before the first fill, covering nutrition support, coverage requirements and treatment options.

“ The pharmacy benefit is not only where plan sponsors can finally get transparent, unconflicted economics. It is also the most frequent touchpoint employees have with their benefits, which makes it the best place to connect them to the broader care available to them, improving outcomes and reducing the total cost of care. “

Indication matters enormously here and is routinely overlooked: obesity, cardiovascular risk reduction and MASH are three different clinical pathways, and a benefit design that is defensible for one, can be difficult to justify for another. Acting at the point of prescription is what makes that distinction visible in time to do anything about it. The same idea applies elsewhere. An employee starting an antidepressant may benefit from virtual mental health support, and someone beginning a specialty drug may need help with prior authorization, site of care or treatment planning. Pharmacy-led navigation puts pharmacy at the center of the benefits strategy, using these moments to connect employees with relevant benefits and clinical support when it matters most. By pharmacy-led navigation, I mean treating the prescription event itself as the trigger for outreach, to inform the member of the best next step rather than leaving the member to find it.

Many employers manage pharmacy and medical benefits through separate systems, which makes it harder to see the full cost and care picture, especially with high-cost specialty therapies that often span both. A connected view helps employers manage those costs with one coordinated strategy instead of separate rules and vendors, and lets benefits leaders identify lower-cost, clinically appropriate options earlier and understand how point solutions, care programs and site-of-care choices affect total spend.

Bringing Transparency to Pharmacy Decisions

Employers are asking more of their PBM partners: clear pricing, full visibility into fees and more control over drug costs, including full rebate pass-through and no spread pricing. This is not only good practice. As ERISA fiduciaries, plan sponsors carry an affirmative duty of prudence, which means understanding their population and documenting a reasoned basis for benefit decisions, and that is difficult to do credibly when pharmacy and medical sit in separate systems. At Transcarent, we’ve built our platform around this principle, and pairing transparent pricing with real-time guidance has lifted benefit engagement by more than 20% across our book of business, measured against pre-launch baseline.

But employees need that same clarity at the point of care: the ability to see relevant prices before a prescription is filled, know when a lower-cost alternative exists, and understand what to do next. That guidance can come through digital tools, AI support, pharmacists, or care teams, but consumers should know their options before they pay.

Connecting Benefits around the Consumer

Pharmacy can also be the bridge that connects the benefits employers already offer, from behavioral health and weight health to virtual care and specialty programs. A new prescription can trigger outreach, and a pattern of missed fills can prompt a check-in, helping employees use benefits their employer already funds. Benefits leaders have heard integration promised for a decade, so the fair test is not whether a partner claims it but whether pharmacy and medical data actually land in one place, and whether one team is accountable when a member falls through. Employers need partners that share data and align around cost and outcomes, or even strong programs can feel separate and underutilized.

Pharmacy strategy has long focused on rebates, discounts, network terms and contract renewals. Those areas still matter, but it's time for pharmacy-led navigation to play a larger role, pairing that expanded scope with realtime guidance that helps employees make better choices before a claim is filled. Start with one question for your PBM: when a lower-cost, clinically appropriate option exists for a drug we are paying full price on, what triggers surfacing it to us, and on what timeline? The answer will tell you whether pharmacy is operating as the foundation of your health and care strategy, or simply as its largest line item.