A practical guide for brokers on reviewing pharmacy benefits before open enrollment, reducing plan disruption, identifying Rx cost drivers, and helping employers make clearer renewal decisions
Table of Contents
- Open enrollment pressure often starts with pharmacy
- Why Rx deserves attention before open enrollment decisions are finalized
- The Rx cost drivers brokers should review first
- Where PBM details can create open enrollment confusion
- How Rx decisions affect employees during open enrollment
- The broker’s Rx checklist before recommendations are locked in
- How better Rx visibility helps brokers reduce disruption
- What employers need to hear before open enrollment
- Rx should be part of the open enrollment strategy early
- Key takeaways
Open enrollment pressure often starts with pharmacy
By the time open enrollment decisions are close to being finalized, employers usually want three things from their broker: clear recommendations, fewer surprises, and as little employee disruption as possible.
Pharmacy benefits can affect all three.
A plan may look ready from a medical, network, and contribution standpoint, while pharmacy questions are still sitting underneath the surface. Which high-cost medications are driving spend? Which drugs could create member disruption? Are GLP-1s covered, limited, or excluded? Are employees likely to face higher out-of-pocket costs at the pharmacy counter? Can HR explain the prescription benefit clearly?
Those details matter because employers are already reviewing plan costs closely. Mercer reported that total health benefit costs are expected to increase 6.7% in 2026, pushing the average cost above $18,500 per employee.¹
That gives brokers a practical reason to bring pharmacy into the conversation early. When prescription costs, PBM terms, and employee communication are reviewed too late, the renewal discussion can become harder to explain and harder to defend.
Why Rx deserves attention before open enrollment decisions are finalized
Pharmacy spend is one of the areas employers can feel quickly.
A single specialty medication, a growing GLP-1 trend, or a group of employees with recurring high-cost prescriptions can change the cost picture. Employees may also notice pharmacy changes faster than other plan changes because prescriptions are often refilled every month.
In the same Mercer report, prescription drug benefits were listed as one of the fastest-growing expense categories, rising about 9% in 2026. That makes Rx one of the cost areas brokers should review before final recommendations are locked in.
For brokers, this review should answer practical questions:
- What is driving pharmacy spend?
- Which medications are creating the most pressure?
- Are there plan design issues that could create employee confusion?
- Can the employer explain what is changing in plain language?
- Is there a process to help employees when a prescription is delayed, denied, expensive, or hard to understand?
These questions can help brokers move from a renewal number to a clearer recommendation.
The Rx cost drivers brokers should review first
Pharmacy review does not need to cover every drug in the plan. It should start with the areas most likely to affect cost, disruption, and employee questions.
Specialty medications
Specialty medications often require a closer look because they can carry high costs, need special handling, or involve more clinical review. A small number of prescriptions can shape a large part of the pharmacy conversation.
Brokers should look at which specialty medications are driving spend, whether those medications are being billed through the pharmacy or medical benefit, and whether lower-cost options exist. It also helps to review whether employees using those medications have a clear support path.
For employers, the issue is not only the price of the drug. It is whether the plan has a process for managing the medication without leaving the employee or HR team guessing.
GLP-1 utilization and coverage rules
GLP-1s need their own review because coverage decisions can affect cost, employee expectations, and plan communication.
Employers need to understand who is eligible, whether the medication is covered for diabetes, weight loss, or both, what diagnosis rules apply, whether prior authorization is required, and what the plan’s cost exposure could be.
PwC reported that large self-funded employers covering GLP-1s for weight loss are seeing pharmacy trend increases exceeding 20% year over year.²
That does not mean every employer should make the same coverage decision. It means brokers should help employers make the decision with clear rules, clear cost expectations, and clear employee messaging.
Chronic condition medications
Medications for diabetes, autoimmune conditions, cardiovascular conditions, asthma, and other chronic needs can affect both plan spend and employee experience.
These prescriptions are often recurring. If coverage changes, copays increase, or pharmacy access becomes confusing, employees may notice quickly.
A useful review should identify whether employees are facing avoidable cost barriers, whether preferred drugs are clearly communicated, and whether members know where to go for help.
Where PBM details can create open enrollment confusion
PBM details can be hard to explain when they are reviewed too late. Brokers do not need to turn every employer meeting into a PBM contract review, but a few areas should be clear before employee materials are finalized.
Formularies and exclusions
The formulary tells members which medications are covered, preferred, non-preferred, or excluded. When employees learn about a formulary issue at the pharmacy counter, the question often comes back to HR.
Brokers should clarify whether any common or high-cost medications may be affected. If there are exclusions, step therapy rules, or preferred alternatives, employers need enough information to explain what employees should do next.
The goal is not to prevent every question. The goal is to avoid preventable confusion.
Rebates, discounts, and savings
Employers may hear terms like rebates, discounts, guarantees, and spread pricing without seeing how those items affect their plan.
Before open enrollment, brokers should know how pharmacy savings are handled and whether the employer can see the impact clearly. If savings are being discussed as part of the recommendation, the employer should understand where they come from, how they are measured, and how they affect the plan.
Clear reporting helps employers feel less dependent on broad explanations.
Prior authorization and member support
Prior authorization can be a valid clinical and cost management tool, but it can also create frustration when employees do not understand the process.
Brokers should review what requires prior authorization, how employees are notified, what support is available, and how long the process typically takes. The employer should also know who helps the member when a prescription is delayed, denied, expensive, or confusing.
This is where member support matters. Employees need a clear next step, and HR should not have to manage every prescription issue alone.
How Rx decisions affect employees during open enrollment
Employees may not read every plan detail, but they usually pay attention when a medication they use changes.
Prescription benefits feel personal because they are tied to daily routines, chronic care, family needs, and monthly expenses. A drug that is no longer covered, a higher copay, or a new prior authorization requirement can quickly become an employee complaint.
That does not mean brokers should avoid recommending pharmacy changes. It means those changes need to be explained clearly.
Employees need to know:
- What is changing
- When the change starts
- Which prescriptions may be affected
- What lower-cost options may be available
- Who to contact for help
- What to do if a medication is denied or costs more than expected
When this information is missing, employees may assume the plan is broken, even when the issue has a process behind it.
The broker’s Rx checklist before recommendations are locked in
Before recommendations are finalized, brokers should review the pharmacy benefit through both a cost lens and an employee experience lens.
A practical Rx checklist should include:
- Top 10 drugs by plan spend
- Specialty drug utilization
- GLP-1 coverage and controls
- Member out-of-pocket costs
- Prior authorization process
- Rebate and discount transparency
- Lower-cost sourcing opportunities
- Employee communication needs
This checklist can help brokers identify where the employer may need a clearer explanation, a plan adjustment, or additional member support before open enrollment begins.
For a deeper renewal conversation, brokers can also use these pharmacy questions employers should ask before renewal to guide employers through spend drivers, specialty medication concerns, rebate visibility, member costs, and savings opportunities before decisions are locked in.
How better Rx visibility helps brokers reduce disruption
Better pharmacy visibility helps brokers catch issues before employees experience them.
That means seeing more than total pharmacy spend. Brokers need enough detail to understand which medications are driving cost, which members may face access issues, and which plan rules could create confusion.
Drug-level reporting can help identify high-cost opportunities. Member support data can show where employees may need more guidance. Prior authorization reporting can help employers understand whether the process is working as intended.
This level of review also helps brokers speak more clearly with employers. Instead of saying pharmacy spend is up, the broker can explain what is driving the increase, what can be reviewed, and what employees may need to know.
What employers need to hear before open enrollment
Employers do not need every technical detail behind the pharmacy benefit. They need the parts that affect decisions, costs, and employee communication.
Before open enrollment, brokers should be ready to explain:
- What is changing in the pharmacy benefit
- Why the change is being recommended
- Which medications or drug categories may be affected
- How employees can get help
- What the employer should include in open enrollment materials
- What HR should say if employees ask about expensive prescriptions
Plain-English communication matters here. If the employer understands the pharmacy recommendation clearly, the employee communication is usually stronger too.
Rx should be part of the open enrollment strategy early
Pharmacy benefits should not be treated as a final detail after the plan recommendation is mostly finished.
For brokers, an early Rx review can make the renewal conversation more specific. It can help explain cost drivers, identify disruption risks, and prepare employers for employee questions before they happen.
Need a clearer view of pharmacy costs before open enrollment? Intercept Rx can help brokers identify Rx savings opportunities and reduce plan disruption before decisions are finalized.
Key Takeaways
- Pharmacy benefits can affect renewal costs, employee questions, and open enrollment confidence.
- Brokers should review specialty medications, GLP-1 utilization, chronic condition drugs, member costs, and prior authorization before recommendations are finalized.
- PBM details like formularies, exclusions, rebates, discounts, and member support should be clarified before employee materials are prepared.
- Employees usually notice pharmacy changes quickly because prescriptions are personal, recurring, and tied to daily health needs.
- A clear Rx review gives brokers stronger talking points and helps employers reduce last-minute confusion.
