What a New PBM Model Changes for HR Accountability

Pharmacy benefits are one of the hardest areas for HR to defend as drug costs climb. Employees feel it at the pharmacy counter. Finance sees it in renewal projections. HR ends up explaining the gap.

Medical and prescription drug expenses are projected to rise by 8.4% this year, according to HUB International’s 2026 Benefits Cost Trends Report. Now, many employers are reexamining pharmacy benefit options, including a new Medication Optimization PBM approach.

A New PBM Operating Model Enters the Conversation

EmpiRx Health recently announced the launch of its new Medication Optimization (MO) operating model. The company describes the approach as a shift away from price-first PBM management toward sustained clinical accountability across the plan year.

“From day one, our mission has been to reimagine pharmacy care by shifting the PBM operating model from emphasizing transactions to focusing on patient health outcomes,” said Danny Sanchez, Chief Executive Officer of EmpiRx Health, in announcing the model.

From Price Management to Clinical Accountability

Traditional PBM arrangements concentrate most control at the front end. Access challenges tied to pharmacy closures have added urgency to how employers structure and evaluate benefits. Pricing terms get negotiated. Formularies get set. Access rules get defined. After prescriptions are filled, employers often have limited insight into how medication use changes.

That structure creates a familiar problem. Pharmacy trends shift midyear, yet the drivers behind those changes are difficult to identify. Limited visibility is also drawing regulatory attention, as states like California move to require greater transparency and accountability from PBMs (see related PBM reform in Arkansas). Cost controls may exist on paper, but spending continues to climb without a clear explanation tied to medication decisions.

Employers now ask who monitors medication use once coverage is live, who intervenes when therapy no longer aligns with treatment goals, and who owns outcomes as utilization and costs change.

How the Medication Optimization Model Works

Under its Medication Optimization model, EmpiRx Health places that responsibility back with the PBM.

The MO approach relies on active, pharmacist-led monitoring rather than periodic utilization reviews. Clinical pharmacists track therapy patterns as they develop and intervene when medications are duplicative, ineffective, or no longer align with clinical guidelines.

That oversight continues beyond initial approvals. Pharmacists review dosing concerns, treatment effectiveness, and overlapping therapies, contacting prescribers when changes are warranted. Member outreach focuses on issues that commonly disrupt treatment, including side effects and affordability concerns.

The model pairs this clinical work with internal systems that flag risk and help prioritize intervention earlier while employees are still in treatment, instead of after utilization and costs escalate. It also relies on EmpiRx Health’s Clinically technology platform, which supports pharmacist-led medication review and helps surface potential therapy issues.

That shift has drawn attention beyond EmpiRx Health itself.

“Medication Optimization is the innovative, clinically focused breakthrough the PBM industry has long needed,” said Jim Tsipakis, RPh, former President, Supermarkets & Pharmacy, at Giant Eagle.

Tsipakis explained MO as a shift back to pharmacist-led care and clearer accountability for medication outcomes, noting that traditional PBM models have struggled to deliver that level of clinical ownership.

PBM Operating Models and Employer Accountability

The impact of a PBM operating model becomes clearer over the course of the plan year. Pricing establishes the baseline. Ongoing management determines how pharmacy results evolve.

EmpiRx Health describes Medication Optimization as an approach that keeps clinical responsibility with the PBM throughout the year. That framing reflects employer concern about absorbing risk when pharmacy outcomes shift after enrollment.

As more PBMs move toward active clinical oversight, HR teams may face growing pressure to distinguish price-focused contracts from those built around year-round accountability.

Employer focus continues to move toward ownership. Pharmacy outcomes invite less scrutiny when responsibility for oversight is clear and documented, especially when Finance asks why spending shifted midyear.

Questions HR Teams Rely on to Press PBM Vendors

When reviewing PBM options, HR teams focus on questions that clarify how pharmacy decisions are managed and explained after enrollment:

• What clinical review activities occur after prescriptions are approved?
• What reporting shows when interventions happen during the plan year?
• What documentation supports decisions made on high-cost or complex therapies?
• How does the PBM explain pharmacy cost changes outside of utilization spikes?
• How are pharmacy trends communicated to employers ahead of renewal discussions?