The End of the Autopilot Era: Employers Tear Up PBM Contracts

DALLAS, TX – September 29, 2026 – For years, the renewal of a Pharmacy Benefit Manager (PBM) contract was a corporate formality—a rubber-stamped approval driven by the sheer administrative dread of migrating thousands of employees to a new network. But the era of the autopilot renewal has officially collapsed.

According to the newly released 2026 Pharmacy Benefit Manager Customer Satisfaction Report by Pharmaceutical Strategies Group (PSG), an EPIC company, employer frustration with opaque revenue models and restrictive specialty drug management has reached a critical mass. While overall customer satisfaction with PBMs stabilized this year at 7.2 out of 10—halting a multi-year slide from a high of 8.2 in 2021—the willingness of plan sponsors to renew their contracts without issuing a competitive Request for Proposal (RFP) has plummeted to an all-time low of 6.4.

This data, drawn from 250 benefits leaders representing employers, health plans, and health systems, signals a pivotal shift in the healthcare procurement landscape. Corporate benefits directors are no longer waiting for legislative salvation; they are weaponizing the RFP process to dismantle entrenched business models and demand actionable transparency.

The Procurement Revolt and the Flight from the 'Big Three'

The modern PBM landscape is notoriously concentrated. Recent analysis indicates that the "Big Three" PBMs—CVS Caremark, Express Scripts, and OptumRx—still control approximately 75 to 80 percent of the national market share. However, PSG’s findings suggest their iron grip on commercial plan sponsors is slipping as mid-market, transparent alternatives gain unprecedented traction.

Nearly 70 percent of respondents reported including at least one non-Big Three PBM in their most recent RFP, and an overwhelming 82 percent stated they would be at least moderately interested in exploring alternative PBMs if they were conducting a procurement today.

“Customers are demanding more from their PBMs, especially when it comes to managing costs and providing greater visibility,” said Mike Medel, Senior Vice President and Practice Lead, Plan Sponsor at PSG. "We’re also starting to see satisfaction decline among non-Big 3 PBMs, which drives home that these challenges aren’t exclusive to the biggest players in pharmacy benefit management.”

Indeed, while non-Big Three PBMs have historically enjoyed a halo effect of high customer approval, their satisfaction scores dropped sharply from 7.9 in 2025 to 7.3 in 2026. This decline suggests that as these alternative PBMs scale to absorb fleeing employer groups, they are encountering the same systemic friction points—particularly the immense difficulty of managing runaway drug trend costs without resorting to the very spread-pricing and restrictive formulary tactics that alienate clients.

The Specialty Drug Trap and Contractual Handcuffs

The bleeding edge of drug trend costs is no longer found at the retail pharmacy counter; it is concentrated in specialty medications. High-cost therapies, particularly the explosion of GLP-1 agonists for diabetes and weight loss, alongside complex oncology regimens, have fundamentally altered the financial risk profile for self-funded employers.

To combat these costs, many plan sponsors are attempting to "unbundle" their benefits, seeking to carve out specialty pharmacy management to independent vendors who offer better clinical oversight and lower net costs. Yet, the PSG report exposes a severe disconnect between employer intent and contractual reality.

While over half of the surveyed benefits leaders expressed strong interest in carving out specialty pharmacy, 41 percent admitted they were unsure if their current PBM contract even allowed the use of third-party carve-out vendors. More alarmingly, only 15 percent were confident they could execute a carve-out without triggering steep financial penalties or rebate forfeitures.

Healthcare antitrust attorneys and procurement specialists note that legacy PBM contracts are often laced with restrictive covenants. These clauses act as a financial trap, penalizing employers who attempt to route high-margin specialty prescriptions away from a PBM’s wholly-owned specialty dispensing pharmacies. By tying comprehensive retail rebates to exclusive specialty dispensing rights, dominant PBMs effectively lock plan sponsors into a closed ecosystem, shielding their most lucrative revenue streams from free-market competition.

The Black Box of PBM Revenue

The core grievance driving the RFP revolt remains the fundamental opacity of how PBMs make their money. Despite years of congressional hearings and public outcry, "sources of revenue" remains the lowest-rated aspect of PBM transparency in the PSG report. One in five respondents rated their PBM as "not at all transparent" regarding its revenue generation.

"We're continuing to see that customers lack full visibility into how their PBM makes money and whether its revenue sources are creating conflicts of interest," said Morgan Lee, Vice President of Research and Marketing at PSG. "There's an opportunity for more transparency in this area, which would empower customers to make more informed decisions on strategies they may want to pursue to ensure their pharmacy benefit is managed in accordance with their priorities."

The financial mechanics obscured from employers are vast. Academic research from the USC Schaeffer Center has previously demonstrated that roughly 41 cents of every dollar spent on prescription drugs flows to intermediaries rather than manufacturers. Furthermore, the reliance on manufacturer administrative fees, rebate retention, and spread pricing creates misaligned incentives, where PBM profits are often correlated with higher list prices rather than the lowest net cost for the patient.

While alternative pricing models are gaining ground—roughly 61 percent of payers now utilize some form of pass-through pricing—the complex vertical integration of PBMs, insurers, and pharmacies makes it exceedingly difficult for employers to trace the true flow of healthcare dollars.

Regulatory Skepticism: Why Washington Can't Fix the Commercial Market

In response to mounting public pressure, federal and state regulators have launched a barrage of legislative and enforcement actions. The Consolidated Appropriations Act of 2026 (CAA 2026) mandates 100 percent rebate pass-through and the elimination of spread pricing for qualifying self-funded ERISA plans by 2029. Meanwhile, states like California have already implemented bans on spread pricing, and the Federal Trade Commission continues to aggressively scrutinize PBM business practices.

Yet, corporate benefits leaders remain profoundly skeptical that government intervention will yield tangible relief. According to the PSG report, nearly two-thirds of respondents rated their desire for PBM industry change at seven or higher on a 10-point scale, but the majority expect recent regulatory developments to have only a minor to moderate impact on transparency and their actual customer experience.

“This year's findings show that customers want real change across the industry as they grapple with high costs in pharmacy benefits and healthcare more broadly,” said Mike Lonergan, President of PSG. “For over 20 years, our Pharmacy Benefit Manager Customer Satisfaction Report has helped us understand where the biggest concerns are, where PBMs are making progress, and where there's still room for improvement."

This skepticism is rooted in a pragmatic understanding of the healthcare market. Regulatory mandates often target the symptoms of market failure rather than the root causes, and PBMs have historically demonstrated an agile ability to pivot their revenue models in response to new laws. As spread pricing is outlawed, revenue generation simply shifts to new, unregulated fees levied on manufacturers or pharmacies.

For corporate leaders, the takeaway is clear: waiting for Washington to fix the pharmacy supply chain is not a viable business strategy. Instead, plan sponsors are realizing that the only effective mechanism for reform is the rigorous, uncompromising execution of their own procurement power. The automatic renewal is dead, and the era of the activist employer has arrived.