How Employers Can Cut Pharmacy Costs Without Changing Their PBM

The pharmacy cost dilemma won’t just disappear

Prescription drug costs have become one of the hardest problems on a benefits leader's desk. Specialty medications, gene therapies and the rapid rise of GLP-1s are pushing pharmacy spend higher every year, and the pressure shows no sign of easing. For employers at the median of those surveyed by the Business Group on Health, pharmacy costs grew from 21% of total healthcare dollars spent in 2021 to 27% in 2023. For many self-insured employers, pharmacy claims are now climbing at double-digit rates annually, sometimes at twice or more the pace of medical claims.

Faced with those numbers, many employers assume the only real fix is to rip out their Pharmacy Benefit Manager (PBM) and start over. But, renegotiating or switching PBMs is complex and requires plenty of effort, which may not be possible for every organization.

Here's the more useful truth: there are powerful, effective strategies employers can use to rein in pharmacy spend and improve care within their existing benefits structure. You do not have to change PBMs to gain control.

This guide walks through the practical levers that work: targeted formulary strategies, proactive specialty drug management and clear rules for GLP-1s, along with the role an independent, clinically led navigation partner plays in tying it all together. Quantum Health has expanded its own approach here through Pharmacy Navigation from Quantum Health, powered by Scripta to target everyday drug costs and Aradigm to help manage the massive, unpredictable claims tied to cell and gene therapies.

Beyond the PBM contract: Finding untapped savings

A well-negotiated PBM contract matters. But contract terms alone rarely explain why one employer's pharmacy trend looks so different from another's. The bigger driver is how the benefit actually gets used by members, and that happens well before any claim reaches the PBM.

A PBM adjudicates prescriptions after a physician writes them and a member fills them. It reacts to claims. It cannot proactively guide a newly diagnosed member through what is often an unwanted and confusing journey, help them weigh a lower-cost clinical equivalent, or steer them toward a more affordable place to receive an infusion. By the time the PBM sees the cost, the decision has already been made. Recent scrutiny of practices like spread pricing and rebate retention has made many employers rethink how much visibility they truly have.

This is where a clinically led, independent navigation partner earns its place. It isn't a replacement for the PBM. It's the optimization layer that sits on top of the plan and works on behalf of the employer and the member, making sure the benefit gets used in the most clinically appropriate and cost-effective way possible. Smart benefits teams are increasingly focused on this kind of mid-year optimization rather than plan overhauls, an approach that some brokers are using to cut pharmacy spend without changing the health plan [2].

Tackling the biggest cost drivers: Specialty drugs and GLP-1s

If you want to move your pharmacy trend, this is where to concentrate your energy. 2025 UnitedHealthcare data showed that specialty medications represented less than 2% of overall pharmacy volume, but more than 60% of total pharmacy spending.

Layered on top of that is the explosive growth of GLP-1 drugs for weight loss, which has added a fresh and unpredictable source of cost pressure across nearly every plan.

You cannot manage this kind of volatility by simply reacting to claims after they’re processed. It takes a dedicated, clinically led approach that engages members before the most expensive decisions are locked in.

What employers should know: A clinically led approach to medical-benefit specialty drugs

Specialty drugs may be covered under either the pharmacy benefit or the medical benefit. The strategies below focus specifically on infused and injected therapies billed through the medical benefit. Managing PBM-administered pharmacy spend involves a different set of strategies and should be addressed separately.

An independent clinical team can help manage medical-benefit specialty drug costs through rigorous utilization management and site-of-care optimization. Together, these strategies help confirm that treatment is clinically appropriate and delivered in a setting that supports both the member and the health plan.

Prior authorization

Nurses and pharmacists review treatment requests and work directly with providers to confirm that the requested drug, dose and course of treatment meet clinical criteria. This approach can help prevent unnecessary utilization while supporting timely access to appropriate care.

Across its broader utilization management model, Quantum Health reports a 2% denial rate compared with the standard carrier rate of 9%. This reflects an approach designed to resolve questions with providers and approve appropriate care rather than create unnecessary barriers.

Site-of-care optimization

The setting in which an infusion or injection is administered can significantly affect its cost. The same therapy may cost considerably more in a hospital outpatient department than in a physician’s office, an independent infusion center or the member’s home.

A proactive navigation partner can identify clinically appropriate opportunities to move treatment to a lower-cost setting. The clinical team coordinates with the prescribing provider, treatment facility and member to support the transition without disrupting care.

Prior authorization and site-of-care optimization address specialty drug costs paid through the medical benefit. Pharmacy-benefit strategies, including formulary management, prescription savings and other PBM-related levers, should be presented as a separate component of an employer’s broader specialty drug strategy.

What employers should know: Gaining control over GLP-1 spending

GLP-1s call for clear plan rules and compassionate guidance, not blanket denials. An independent partner can help you set and enforce policies that cover GLP-1s for a diagnosed condition like type 2 diabetes while applying different clinical criteria for weight loss use.

Just as important, the approach should be holistic. When a member is seeking weight loss support, a navigation team can guide them toward other effective benefits, including lifestyle and wellness programs, so they still get meaningful help while the plan stays within budget. Members are far more receptive to that kind of guidance when it comes with real support rather than a flat no, which is why proactive engagement and adherence support matter so much when employees are struggling with prescription costs.

Quantum Health's GLP-1 and Pharmacy solution helps self-insured employers save money by guiding members to cost-effective, clinically equivalent alternatives. In partnership with Vida, we ensure that these high-cost drugs are prescribed responsibly. Developing a clear strategy for GLP-1s is a key component of building smarter pharmacy benefits.

An independent navigation partner works for you and your members, not the insurance carrier or the PBM. That distinction shapes every recommendation. The sole focus is guiding members to the best clinical outcome, and when that happens consistently, costs come down as a natural result.

Quantum Health is the creator and leader in healthcare navigation, with more than 26 years of proprietary data behind its model. That combination of clinical expertise and independence is what makes the savings in this article achievable inside your existing plan.

Proactive engagement is the deciding factor

The defining difference in Quantum Health's model is timing. Using predictive AI, Quantum Health engages members an average of 90 days before the first claim is filed. Only Quantum Health engages continuously with providers to take action at a member's first moment of need.

For pharmacy, this early engagement is where the savings live. When a clinician connects with a member at the point of diagnosis, or before a new high-cost prescription is refilled, there's time to guide them to a cost-effective pharmacy, explain the formulary rules, and begin site-of-care planning. A PBM's model is reactive, only registering the cost after the decision is already made and the claim is in.

This forward-looking approach is one of the bold steps employers can take to play the long game on cost and quality.

Integrating pharmacy and medical for a complete picture

Most benefits structures are siloed. Your PBM sees pharmacy claims. Your medical carrier sees medical claims. Neither sees the whole person, and the gaps between them are exactly where cost and complexity pile up.

Quantum Health serves as a single point of contact with an integrated view across both. That lets the clinical team make smarter recommendations and catch decisions early. When a member is diagnosed with multiple sclerosis on the medical side, Quantum Health's team is already working on the optimal site of care and the prior authorization for their specialty drug on the pharmacy side. For the member, it feels like one coordinated, simpler experience. For the employer, it's a less costly one.

Quantum Health: Your partner in smarter pharmacy benefits

Quantum Health delivers every strategy described in this guide, combining site-of-care optimization, utilization management, and proactive high-touch member guidance to reduce costs across specialty and other high-cost drugs, including GLP-1s. The mechanism that brings these savings to life is Quantum Health's pharmacy navigation solution, which uses a clinical pharmacy team to guide members toward cost-effective, clinically equivalent medication alternatives, including biosimilars.

Take control of your pharmacy spend now

You don’t have to be trapped by rising pharmacy costs, and you don't need to switch PBMs to fight back.

The most effective move is to layer in an independent, clinically led navigation partner that optimizes within the existing plan, controls specialty and GLP-1 spend through early engagement and site-of-care management, and gives your members compassionate guidance through decisions they'd rather not have to make alone. It's a non-disruptive path to measurable savings and a better experience at the same time.

As you plan for the year ahead, understanding where these trends are heading is critical. Get deeper insights by reading The 2026 Healthcare Navigation Report.