Preparing for open enrollment: Rx benefits redesign holds promise for cost control

• Key Insight: Discover how GLP‑1 and specialty drugs are reshaping PBM strategy and formulary design.
• What's at Stake: Rising specialty drug costs threaten employer budgets, member access, and plan sustainability.
• Expert Quote: "We can open access and lower costs, but not both without trade‑offs," says Mark Campbell, PharmD.
• Source: Bullets generated by AI with editorial review

As the 2026 open-enrollment season beckons, nowhere is the need for better benefits design more urgent than in the prescription drug arena — the fastest-growing portion of group health expenses for decades.  

Centivo Co-founder Alan Cohen notes the exogenous effects of GLP-1s and specialty drug that are driving up health care inflation. And with more employee cost shifting expected, he cautions that "we better get ready for 7% to 15% per year increases in traditional health coverage." 

As utilization of high-cost specialty drugs and GLP-1s continues to soar, it's more critical than ever for employers to partner with the right pharmacy benefits manager (PBM) to implement strategies that keep health plan costs in check while maintaining appropriate access for members, says Mark Campbell, PharmD, chief pharmacy officer for RxBenefits. 

He recommends a PBM that aligns to an employer's needs and goals without any financial conflicts of interest and implementing targeted clinical management that is laser-focused on the biggest trend drivers "so they can realize strategic savings without wholesale, disruptive changes." 

This is part 5 in a multi-part series about advisers' approach to open enrollment. Catch up on the full series here: 

• Part 1: Preparing for open enrollment: Advisers face significant headwinds in Q4
• Part 2: Preparing for open enrollment: Generational tipping point shaping adviser strategies
• Part 3: Preparing for open enrollment: Benefits literacy a linchpin for success
• Part 4: Preparing for open enrollment: This adviser backs hyper-personalized messaging

That approach includes formulary optimization, which involves removing high-cost scripts that don't deliver clinical benefits in favor of lower-cost, clinically equivalent alternatives, as well as human-led prior authorization reviews that ensure appropriate utilization while preventing misuse and waste. He says members with complex, chronic conditions can benefit from high-touch clinical support that ensures they are getting the right drug at the right dose for their specific condition, preventing both wasted spend and adverse events.
One huge trend driver is GLP-1 coverage, which increasingly is being used to help overweight Americans slim down. Campbell cautions brokers not to encourage this benefit offering without also offering a counseling component. 

"People tend to drop off the medications for complications or stop it and gain back their weight," he says, suggesting Tria Health's choose-to-lose personalized weight-management program as a standout that also offers medication access direct from the manufacturer to keep it affordable. 

Read more: 3 strategies to manage healthcare cost increases in your benefit plans

In recently examining RxBenefits' utilization for branded diabetic products, he noticed that GLP-1s are cannibalizing some of the other scripts in that category. The average onset for type 2 diabetes in the 1990s was around the mid-40s, he recalls, whereas today it has moved into the 20s and in some cases the teens. 

"So, we have to be more vigilant about how we address diabetes as a disease because it can lead to extremely serious consequences, including death," he cautions.  

Another area of exploration includes encouraging the uptake of biosimilars. Much like generic drugs, biosimilars are an alternative to licensed brand specialty medication, though the manufacturing process is different.

The trouble is that Campbell says there are several obstacles for biosimilar adoption, which include complex formulary structures partly driven by PBM deals with manufacturers. Also, he explains that many manufacturers of these alternative drugs introduced them at a high wholesale acquisition cost to recoup the investment of developing biosimilars, which has dampened uptake. 

"A lack of clear communication and education about biosimilars has led to hesitancy among prescribers and patients," he says, calling it a substantial missed opportunity for cost savings. "Many remain unfamiliar with biosimilars or perceive them as unproven alternatives." 

The trick is finding the right balance in designing prescription drug coverage. "I've always told clients that I can open up access so that their members will be happy and never call them because they can get whatever they want whenever they want it," Campbell says. "I can also make it so their cost is extremely low, even all the way down to zero, but then tell them, 'You won't be able to walk to your car safely at night.'"