Making More Pharmacy Benefit Choice Work for TPAs and Their Clients

Effective partnerships turn reporting into action, clarify responsibility for eligibility and benefit issues, and help TPAs demonstrate measurable client value.

  • 4 Min read

  • October 28, 2026

Ryan O’Dell

Ryan O’Dell

Chief Revenue Officer
Best Practices
TPA and PBM partnership discussion focused on integrating pharmacy benefits into the broader employer health plan

Self-funded employers have more ways to structure the pharmacy benefit than they did a few years ago.

Different PBM models. Specialty arrangements. Manufacturer programs. Direct-access options. Pharmacy networks. Clinical programs.

More choice can be useful and using data to inform and drive decisions is preferred.

But someone still has to make it all work.

That matters for TPAs because they already sit close to the employer and understand how the broader health plan operates. As pharmacy benefit options multiply, clients may naturally look to their TPA to help make sense of them.

That does not mean the TPA should become the pharmacy benefit integrator.

The more useful question is:

What responsibilities should the TPA focus on, what should the PBM manage, and how can the two work better together?

One TPA consultant I spoke with recently described a pattern he sees in the stronger TPA-PBM relationships. The PBM is not simply selected and handed a piece of the benefit. The teams work together across sales, clinical support, account management, data, and reporting to solve problems and identify opportunities for clients.

The pharmacy benefit is becoming harder to treat as a separate conversation

The TPA may manage medical claims, eligibility, accumulators, and much of the day-to-day administration of the health plan.

The PBM manages the pharmacy benefit.

That division still makes sense.

What is changing is how many pharmacy benefit decisions now touch the rest of the plan.

Business Group on Health reports that pharmacy spending now represents 25% of employer healthcare spending and estimates employer drug costs will rise 12% in 2026.¹

At the same time, employers are evaluating more ways to manage that spend.

One client may want a different specialty strategy. Another may want to evaluate a direct-access option for certain medications. Another may want a different formulary or network approach.

The value of choice depends on whether the operating model can support it.

The TPA does not need to build a PBM to play a bigger role

A TPA may want a stronger pharmacy benefit proposition for its employer clients.

It may want more influence over how the pharmacy benefit fits with the broader plan, which options clients can choose, what the service experience looks like and how performance is brought back to the employer.

That is very different from wanting to build pharmacy claims infrastructure, manage pharmacy networks, operate formularies, run specialty programs, or create a clinical organization.

A PBM partner can provide those capabilities, giving the TPA more to bring to the employer relationship without giving its team more pharmacy benefit work to manage.

A good partnership should help the TPA solve real problems

That should show up in practical ways.

The right PBM can help the TPA prepare for employer conversations, align sales and clinical resources, identify recurring service or eligibility issues, and turn pharmacy benefit information into action.

Reporting is a good example. A data dump may show utilization, generic dispensing or specialty spend. A useful partnership asks what the information means.

Which issues are driving calls? Where are eligibility, network, or prior-authorization problems recurring? Which members or therapies may need attention? What should happen next, and who owns it?

The goal is not more reports or more programs. It is giving the TPA information and support it can use to solve client problems and show value.

More choice should not create more integration work

This is where the TPA-PBM relationship becomes especially important.

An employer may want one approach for specialty, another for a particular drug category and a different access path for certain medications.

Those choices still have to work inside a health plan.

Eligibility has to be right.

Accumulator information must move correctly.

Benefit rules have to be applied.

Data must get where it needs to go.

Members need to know where to turn.

And when something goes wrong, somebody has to own the next step.

The employer should not have to figure out which organization is responsible.

The TPA should not automatically inherit that work either.

The PBM should be accountable for the pharmacy benefit work it agrees to perform

A valuable PBM partner should be able to run the pharmacy benefit while fitting into the way the TPA serves its clients.

Claims still must process correctly. Clinical programs still have to work. Pharmacy networks, formulary management, specialty strategies, and member support still require real operating depth.

If another partner is involved, the roles should still be clear.

Who connects the data?

Who applies the benefit rules?

Who owns the next step when a member has an issue?

Who makes the change when the employer decides to do something different?

The TPA needs to know those answers without becoming responsible for managing every connection itself.

The PBM should bring clear answers and next steps into the TPA’s sales, clinical and account conversations. The TPA should not have to interpret raw reporting, chase several teams, or discover the same recurring problem at the next client review.

A stronger pharmacy benefit should strengthen the TPA relationship

A stronger pharmacy benefit should give the TPA more to bring to that relationship without giving its own team more pharmacy benefit work to manage.

That requires more than options.

It requires clear responsibilities and a PBM partner that can carry the pharmacy benefit work it has agreed to perform.

The question for TPAs is not:

Should we become a PBM?

A better question is:

What do our clients expect us to manage, what should our PBM partner manage and what should we be able to improve together?

That is the more important conversation as pharmacy benefit choices continue to grow.

That conversation can start with your next employer opportunity or renewal.

In a 30-minute TPA Growth Opportunity Review, we’ll explore how LucyRx can help strengthen your pharmacy benefit offering, clarify implementation responsibilities and support the member experience, with your growth priorities guiding the discussion.

Tags

PBM Partnerships Pharmacy benefits TPA TPA Partnerships

Sources

¹ Business Group on Health “Cost Volatility Forces Employers To Reassess Healthcare Strategy, Business Group on Health Survey Reveals.” August 25, 2026.
URL: https://www.businessgrouphealth.org/newsroom/news-and-press-releases/press-releases/2027-employer-healthcare-strategy-survey

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