When Planned Administrators, Inc. (PAI) serves as the TPA and OptumRx^® is selected as the PBM, employers can gain access to national scale, clinical resources, and enhanced data visibility to support informed decision‑making.

The 2026 opportunity: employers are not limited to PBM services alone. They can layer in specialty drug management, care navigation, digital health programs, and independent audits—while PAI coordinates integration so members experience a cohesive program and sponsors receive consolidated reporting.

Bottom line: PAI + OptumRx provide a foundational framework; employers can then integrate additional partners where they add value. Together, this approach helps employers address pharmacy trend drivers while preserving access and member experience.

The Self‑Funding Advantage—Supported by PAI + OptumRx

Financial oversight and transparency

Self‑funded plans can access detailed insights into utilization patterns, cost drivers, and financial performance when contracts and data‑sharing provisions allow. Nationally, U.S. prescription drug expenditures reached $805.9 billion in 2024, increasing 10.2% year over year, with 9%–11% growth projected for 2025—driven largely by specialty medicines and increased outpatient/clinic utilization.^[1]

PAI Analytics: PAI aggregates medical, pharmacy, and wellness data into a centralized warehouse and dashboard, enabling employers to monitor total cost of care across settings—not just unit price.

When pharmacy and medical claims are viewed together, employers can identify opportunities such as site‑of‑care optimization (e.g., shifting certain infusions from higher‑cost hospital settings to preferred ambulatory locations), subject to plan design and clinical appropriateness. This matters because clinic drug spend has been rising faster than hospital drug spend in national projections.^[1]

Governance focus: Employers may establish net‑cost performance indicators—such as PMPM or cost per claim—by therapeutic class and evaluate PBM and specialty partners against those metrics.

Deep Dive: Biosimilars as a 2026 Cost Strategy

Biosimilars are FDA‑approved biologic medicines that are highly similar to their reference products with no clinically meaningful differences in safety, purity, and potency.^[2]

Over the past decade, biosimilars have generated an estimated $36 billion in U.S. healthcare savings, including $12.4 billion in 2023 alone, while expanding access to biologic therapies.^[3]

Biologics are also a major cost driver: IQVIA reports biologics make up roughly 46% of total medicine spending in the U.S., underscoring why biosimilar adoption is an important planning lever for employers.^[4]

Why biosimilars matter

• Safety and efficacy: FDA‑approved biosimilars meet rigorous standards for quality, safety, and effectiveness. ^[2]
• Savings potential: Reported U.S. biosimilar savings total $36B since 2015, including $12.4B in 2023. ^[3]
• Uptake varies by molecule: Adoption differs widely across products, making targeted implementation essential. ^[5]

A biosimilar‑first framework (with PAI + OptumRx)

Where clinically appropriate and permitted by plan design and state law (including applicable biosimilar substitution/interchangeability requirements), employers may consider:

• Prioritizing biosimilars on formulary
• Applying step therapy protocols that consider biosimilars before reference biologics
• Structuring prior authorization (PA) criteria that support biosimilar use
• Aligning formulary decisions to lowest net cost, not highest rebate
• Tracking performance metrics such as net cost per claim, PMPM, and adoption rates by molecule
• Including biosimilar performance in quarterly leadership reviews

Education also plays a role—supporting providers and members with clear information on safety, efficacy, and cost considerations. ^[2]

Pro Tip: Where available for participating providers, OptumRx’s PreCheck MyScript^® may support biosimilar‑first strategies by offering prescribers real‑time formulary status, cost information, and PA requirements at the point of prescribing.

Beyond the PBM: Integrated Capabilities Coordinated by PAI

Specialty drug management

Specialty drugs are a key contributor to pharmacy spend growth and are frequently cited among the major drivers of rising national expenditures. ^[1] Employers may choose to partner with specialized vendors to help manage utilization, optimize site of care, or improve sourcing strategies.

PAI integration: Eligibility, claims, PA status, and reporting from OptumRx and specialty partners can be aligned so employers receive consolidated visibility and members experience consistent communications.

Modular utilization management for high‑cost therapies

As specialty and precision therapies expand, some employers add modular solutions—such as oncology pathways or advanced clinical analytics—to support complex decision‑making. National trends also show continued growth pressure in categories like specialty, endocrine, and oncology drugs. ^[1]

Why Integration Matters for Drug Trend Management

• Drug spending growth has been accelerating nationally, with continued increases projected.^[1]
• Biosimilars offer meaningful savings potential, but adoption requires structured strategies and governance.^[3]
• Integrated data access and auditability support employer oversight and informed governance decisions.

PAI’s Integration Blueprint

Data standards

• Regular eligibility and accumulator file exchanges
• Pharmacy (NCPDP) and medical (EDI 837/835/834) claims available for reporting and analytics
• Shared data definitions to align reporting and performance metrics

Governance and KPIs

• Quarterly Pharmacy & Benefits Oversight Committee
• KPIs may include net cost PMPM, biosimilar adoption by molecule, site‑of‑care migration, adherence indicators, and member satisfaction

Market surveys show increasing employer interest in PBMs perceived as “more transparent.” In one national employer survey reported by Healthcare Finance News, use of alternative/transparent PBMs increased from 12% (2024) to 31% (2025), while reliance on the “Big Three” PBMs declined from 72% to 61% over the same period.^[6]

2026 Planning Considerations

Biosimilar‑first strategies

Applied where clinically appropriate and subject to plan rules, state law, and medical policy. ^[2][3]

GLP‑1 therapy oversight

Coverage varies by plan. Where GLP‑1 therapies are covered, employers may pair them with lifestyle programs and outcomes tracking in accordance with medical necessity and plan terms. National data also indicate endocrine drugs are among categories influencing spending trends and projections. ^[1]

Site‑of‑care optimization

Preferred ambulatory contracting and post‑authorization site steering may help address faster growth in clinic‑based drug spending relative to hospitals. ^[1]

Compliance and Risk Management Support

• Data security: BAAs, SOC2/ISO documentation, access controls
• Oversight documentation: committee minutes, formulary rationale, audit findings
• Change governance: coordinated communications and member impact assessments

The PAI Difference

With PAI as your TPA and OptumRx as your PBM, employers can combine national PBM scale with the flexibility to integrate specialized partners where appropriate. By emphasizing data connectivity, governance discipline, and a coordinated member experience, employers can evolve their pharmacy strategy without fragmentation— positioning their plans to adapt in 2026 and beyond.