The Empowered Employer: What the Employer Shift Means for Commercial Access

For years, when we talked about “commercial access” in pharma strategy sessions, the conversation followed a predictable arc: payer archetypes, national versus regional plans, the Big Three PBMs and how to negotiate around their formulary tiers. Then employer strategy got one or two slides. Employers were treated less as decision-makers and more as background noise in the broader access vision. Anyone making access decisions in the US commercial space knows that this type of framing is dead, but it hasn’t been totally buried just yet. 

Employers are becoming one of the most consequential forces in commercial market access, and most commercial teams still aren’t organized to engage them directly. Historically, manufacturers built their access engines around PBMs and health plans, hiring people who speak that language, leaving employers as an afterthought.  

 

What the Data Is Showing 

The National Alliance of Healthcare Purchaser Coalitions’ 2026 Pulse of the Purchaser survey found that the share of employer-sponsored health plans using one of the three largest PBMs in the US fell nine points in a single year, from 63.4 percent in 2025 to 54.3 percent in 2026. Nine points in twelve months.¹  

Interestingly, though, while all eyes are on large, self-funded employers, the movement was almost entirely driven by employers with fewer than 1,000 employees. Among that smaller cohort, the share adopting a Big Three fell from 69.7 percent in 2025 to 43.8 percent in 2026. Mid-size employers held steady, while the largest employers (10,000 and above) edged down from 75 percent to 72.1 percent. These figures come from the National Alliance’s member network, which skews toward organizations already engaged on pharmacy benefit strategy. This makes the survey a leading indicator rather than a market average, which is more useful when the planning horizon is three years out.¹ 

While we see stability in the market with the largest employers, their intent tells a different story. Among Big Three clients still considering a switch, intent rises with employer size: 47.4 percent among those under 1,000, 57.4 percent among those with 1,000 to 9,999 employees, and 60.4 percent among those with 10,000 or more. Large employers are still the most interested in switching, despite being the slowest to act.¹ What does this mean for access decision-makers? The biggest employers, the ones covering hundreds of thousands of lives, the ones whose formulary decisions ripple across therapeutic markets, are the most interested in change. However, like any large, influential stakeholder looking to make a change that may impact market dynamics, they are methodical about how they plan to do it. 

 

Why Now?

None of this is happening in a vacuum. A few things have recently converged: 

1. Three separate federal actions. The passage of the Consolidated Appropriations Act of 2026 (CAA 2026), the Department of Labor’s proposed rule governing pharmacy benefit manager (PBM) disclosures, and the Federal Trade Commission’s settlement with Express Scripts (ongoing litigation with OptumRx and Caremark)  have sent a remarkably consistent message to the market. That message has echoed the need for more transparency, greater auditability, and increased scrutiny of PBM compensation. For employers, and especially for their benefits consultants and ERISA counsel, this changes the historical risk equation. CAA 2026 strengthens employers’ negotiating leverage and restricts PBMs’ ability to conceal revenue streams, including spread pricing and rebate retention. Audit rights, remittance timing requirements, and clearer definitions of “rebates” and “remuneration” are rapidly becoming baseline contractual expectations rather than optional concessions. These commercial provisions take effect 30 months from the February 3, 2026, enactment, or January 1, 2029, for calendar-year plans. Because PBM contracts typically run across a few years, the agreements signed over the next two renewal cycles are the ones that will be live when these changes “turn on.”² It is important to note that none of the above are fully operative today. One is a proposal, one binds a single PBM starting in 2027, and the CAA lands only in 2029. What has already changed is expectations, and what is likely going to be priced into the next contract.³ 

2. The fiduciary conversation. Post-J&J lawsuit, no HR VP wants to be the person who signed a contract they can’t defend. National Alliance data shows that among Big Three clients, 36 percent reported concern about the integrity of PBM administration, against 12.9 percent of employers using other PBMs¹. That gap is wide enough to be worth taking seriously, particularly since these are employers evaluating their own vendor. 

3. The cost pressure has become unrelenting. According to Mercer’s survey on health and benefit strategies for 2026 (fielded in 2025), 61% of employers with 500 or more employees are actively evaluating new approaches for offering or managing their pharmacy benefits⁴. When six in ten of your customers are actively evaluating alternatives, you are not looking at a stable market. 

 

The Counterargument

There is a credible read of the same facts argued in the press that lands at another conclusion: CAA 2026 does not weaken PBMs, but instead changes what they are optimized for. Lost rebate retention could tighten the levers the PBMs already control. This could lead to wider differentials between formulary tiers, double-step therapy where single-step used to be, PA criteria pulled further into trial inclusion thresholds, and flat formulary access fees replacing the margins that used to sit inside the rebate. The mechanics are already clear: A $2,000 manufacturer rebate that today reaches an employer at $1,700, with the balance retained as an admin fee, could likely become just a $2,000 pass-through plus a service fee that arrives on a separate line.⁵ 

Both arguments are true: employers are diversifying at the plan level, and PBMs are consolidating control at the volume level. If you have blind spots in your access strategy as it relates to one or the other, you will be facing surprises. 

 

The Menu of Options Is Getting Long, and Innovation Is at the Forefront 

Employers aren’t just switching from one Big Three to another, but instead contemplating a genuinely wider range of options. These new options and increased fragmentation are what should be keeping market access leaders up at night; each of these models has a different contracting counterparty. Most of these remain small relative to total prescription volume. Still, while volume remains small, its signal value does not. Some of what is available to the employer community: 

• Transparent, pass-through PBMs. Names like Rightway, Capital Rx, SmithRx, Navitus. Some subcontract services back to majors, so the diligence matters. Pass-through pricing is ultimately a fee structure, not a guarantee of cost savings. 

• Direct-to-employer pharma models. Waltz Health has launched a DTE access model for FDA-approved obesity medications with both Novo Nordisk and Eli Lilly participating.⁶ For employers, the appeal is to avoid disrupting the core PBM relationship while finding workable pricing on a narrow set of drugs that have been hard to cover. These types of offerings can work in parallel with historical channels without replacing them.  

• Transparent drug marketplaces. Mark Cuban Cost Plus Drug Company is challenging legacy pharmacy economics with transparent, fixed price offerings that bypass PBMs and insurance entirely. 

• Modular contracting. Per Mercer, taking a modular approach by contracting with separate entities for various pharmacy benefit management services is still a trailblazing strategy, with just 10% of respondents evaluating it4. Ten percent of a sample of employers with 500+ employees is a small number, but this still represents a significant amount of total covered lives.  

• Foreign-sourced generics and imported specialty drugs, direct primary care partnerships, near-site pharmacies, and hospital direct contracting. 

Employers are willing to try things now that they wouldn’t have considered three years ago, largely because the cost of doing nothing keeps rising. 

 

Where Manufacturers Are Getting It Wrong

Most commercial market access teams still route “employer strategy” through the PBM account team. This worked when the PBM was the effective single point of decision, but the strategy doesn’t work when the employer is actively shopping their PBM, evaluating carve-outs and, in some cases, direct-contracting with manufacturers. The employer isn’t downstream of the PBM anymore.  

The influencer map has also changed. It used to be that the P&T committee, the medical director, and the pharmacy director at the plan drove access outcomes. Now, for a self-insured Fortune 500 employer, decisions are increasingly shaped by the CHRO, the CFO, and, critically, benefits consultants and coalition executives. These people don’t speak clinical trial jargon; they need a value story that demonstrates fiduciary defensibility, transparent pricing, and outcomes they can predict and measure. 

Finally, we continue to underestimate coalitions. Groups like the National Alliance, the Midwest Business Group on Health, the Northeast Business Group on Health, and the Pacific Business Group on Health function as force multipliers. They aggregate purchasing power, share benchmarks, and set peer expectations. When one big employer in a coalition moves, the others hear about it fast, and usually faster than the manufacturer’s account team will. 

To be clear about what this evidence does and does not show: it tells us employer purchasing behavior is fragmenting, but not that formulary outcomes have drastically shifted. The organizational question is whether pharma leadership will be well positioned to react to larger changes when they do happen.  

 

What Manufacturers Should Be Doing

• Segment employers the way you segment payers. By self-insured versus fully insured. By coalition membership. By carve-out status. By PBM contract expiration year. You need a live view of who is renegotiating what and when. 

• Add stop-loss considerations into the picture. For specialty and rare disease, the lever employers often reach for is financial risk transfer, not PBM selection nuances. Stop-loss and reinsurance sit upstream of most of the coverage decisions manufacturers care about, and almost no commercial team is tracking what is used, and in protection of what. 

• Build an actual employer engagement function. If you have a commercial-heavy product, then the employer strategy cannot be baked in the payer team’s deck. Manufacturers that treat employer engagement as a subset of national account management are going to keep missing opportunities to engage these critical customers. 

• Rethink evidence. Employers care about total cost of care, absenteeism, productivity, adherence, and member satisfaction. That’s not the same evidence package a health plan wants.  

• Get comfortable with the transparent PBM ecosystem. Learn who they are, how they contract, and what they need from manufacturers. Some are legitimate disruptors. Others are repackaging similar infrastructure. Knowing the difference is a competitive advantage. 

• Know the benefits consultants. The DOL’s proposed rule pulls entities that advise or make recommendations on pharmacy benefit management services into the covered service provider definition. Regulators are treating the consultant as fiduciary-relevant, where in practice they usually make the first coverage evaluation well before a payer is involved.  

 

A Note on the Fully Insured Side 

The commercial book of business is in a state of disruption. Fully insured commercial plans will evolve, but more gradually. The existing PBM relationships baked into plan design are sticky, and the CAA 2026 opt-in requirement for fully insured plans means the pressure just isn’t the same. Small employers on fully insured plans are largely along for whatever ride the insurance carrier chooses. That’s not going to change overnight, and manufacturer strategies for those segments should reflect that reality. 

The self-insured side carries a different story. That’s where the volume is, that’s where the appetite is, and that’s where the disruption is happening in real time. 

 

In Closing

 This is not a call for reorganization, but instead a reminder to know which employer accounts sit in a contract year, which coalitions are likely to carry the highest influence, and whether anyone on the commercial team can answer either of these questions today. For most organizations, the answer is “not yet,” and that gap is narrow but solvable. 

Questions? Want to discuss further? Contact us at info@petauri.com or visit Petauri Advisors to learn more about how we can support your employer strategy.

 

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References  

1. National Alliance of Healthcare Purchaser Coalitions, 2026 Pulse of the Purchaser Survey,  Aug. 17, 2026. 
2. RxBenefits, “PBM Reform at Midyear 2026: Litigation and Legislative Updates for Self-Insured Plan Sponsors,” 2026. 
3. Frier Levitt, “How Recent Federal Action Is Reshaping PBM Relationships with Commercial Plan Sponsors,” Feb. 10, 2026. 
4. Mercer, Survey on Health & Benefit Strategies for 2026, June 2025. 
5. Modern Healthcare, “What employer frustration signals for the PBM market,” Aug. 12, 2026. 
6. Frier Levitt, “Direct-to-Employer Pharmacy Contracting: Employers Seek Greater Transparency Beyond the PBM Model,” July 14, 2026.