PSG Report Finds Cost Management Remains Payers’ Top Goal as Coverage Strategy for New Drugs and Indications Emerges as Biggest Specialty Drug Management Challenge

New specialty drug benefits research shows growing focus on medical-benefit drugs, rising interest in trading rebates for utilization controls, and increasing scrutiny of PBMs’ management models

DALLAS--(BUSINESS WIRE)--Pharmaceutical Strategies Group (“PSG”), an EPIC company, today released its 2026 Trends in Specialty Drug Benefits Report, providing new insights into how payers are navigating rising specialty drug costs, increasing treatment complexity, and the growing challenge of balancing affordability with access. The report, now in its 13^th year, was co-sponsored by Genentech.

PSG’s research found that payers are placing more attention on specialty drugs covered under the medical benefit, showing greater willingness to accept fewer rebates in exchange for stronger utilization management controls, and re-evaluating whether current PBM management models are aligned with their best interests.

“Payers continue to prioritize managing specialty drug trend and total cost of care,” said Morgan Lee, Vice President of Research and Marketing at PSG. “At the same time, they are working to develop effective coverage strategies for new drugs and expanded indications, take a more integrated approach across pharmacy and medical benefits, and reassess traditional arrangements, including their reliance on rebates.”

Rising Costs and Greater Reach Drive New Challenges

As new, innovative therapies enter the market and patient utilization increases, specialty drugs continue to be a major driver of healthcare trend and a key concern for payers. 43% of respondents ranked management of specialty drug costs as their top goal, followed closely by managing total cost of care.

The growing number of specialty drugs and expanded indications for existing drugs is also creating substantial operational complexity for payers across both pharmacy and medical benefits. Payers’ ratings place developing and implementing effective coverage strategies for new drugs and expanded indications as their top challenge, surpassing access to integrated data and affordability for members. PSG’s research found that 72% of payers report having a medical drug formulary, and many are increasingly focused on optimizing their specialty formulary across pharmacy and medical benefits, with 68% indicating this is a focus to a moderate or great extent. Additionally, 50% of employers and 72% of health plans have processes for cross-benefit formulary management, reflecting the increasing need to manage specialty drugs across both pharmacy and medical benefits.

In response to cost pressure, organizations are placing greater emphasis on deeper analysis, with 46% of respondents prioritizing member-level total cost of care evaluation, signaling a shift toward more granular, data-driven cost management strategies. This shift is being accelerated by growing financial uncertainty associated with complex therapies like cell and gene therapies (CGTs), which are driving cost variability and forecasting challenges.

Cell and Gene Therapies Introduce Financial Risk

CGTs have emerged as a key concern for payers, with 85% of health plans and 71% of employers expecting these therapies to create moderate or major financial challenges in the next few years. Respondents also reported limited visibility into future CGT financial impact, hindering their ability to plan and forecast effectively.

Direct engagement with pharmaceutical manufacturers through risk-sharing financial programs is one approach to mitigate this risk, but adoption remains limited: just 5% of employers and 27% of health plans report entering into any CGT-specific risk-sharing financial programs. Despite the high level of financial concern, limited adoption highlights a gap between recognized risk and payers’ ability to fully assess that risk and select the most appropriate risk mitigation strategy.

“While CGTs are highly innovative therapies with the potential to improve patient outcomes, they continue to raise major cost concerns for payers,” said Renee Rayburg, Vice President of Clinical Strategy at PSG. “Many organizations lack confidence in their ability to project future costs and fully understand the financial impact, making it difficult to plan for these therapies effectively. Predicting therapy uptake also remains challenging, particularly in conditions where effective treatments already exist.”

Payers Reevaluate Rebate-Driven Models in Favor of More Control

Rebates have long been a major driver of payers’ specialty drug benefit decisions. However, payers are now showing a growing willingness to reconsider traditional rebate-driven strategies, with two in five organizations willing to accept fewer rebates to implement more utilization management controls, according to PSG’s research.

This signals a broader shift toward prioritizing long-term cost management over short-term financial gains. At the same time, rebate access remains uneven. While 93% of respondents receive rebates under the pharmacy benefit, only 51% receive rebates under the medical benefit. That gap is especially pronounced between employers and health plans, with health plans far more likely to receive medical benefit rebates. This finding points to a structural disadvantage for many employers and further demonstrates how managing specialty drugs across benefits is challenging. Additionally, the report surfaced some skepticism among payers about whether the current model, in which a PBM owns the specialty pharmacy while managing utilization of specialty drugs, acts in their best interest.

Separately, the research indicates that payers generally view the clinical and care management support provided by specialty pharmacies positively but perceive only a moderate degree of differentiation across specialty pharmacies.

“Today’s payers are at a critical juncture, balancing the promise of new therapies with mounting cost pressures,” said Rebekah Gregg, Chief Operations Officer at PSG. “This report is intended to foster deeper dialogue and help stakeholders move toward more effective, outcomes-driven strategies.”

The full report is available here: https://www.psgconsults.com/2026-trends-in-specialty-drug-benefits-report.

About the 2026 Trends in Specialty Drug Benefits Report

The 2026 Trends in Specialty Drug Benefits Report is based on a survey of 228 benefits leaders representing employers, health plans, and unions/Taft-Hartley plans with a median of 12,000 covered lives. It provides in-depth insights into payer strategies, challenges, and emerging trends in specialty drug management. Additional PSG research and prior reports can be found here.

About Pharmaceutical Strategies Group (PSG)

Pharmaceutical Strategies Group (PSG) is an independent pharmacy benefits consultant, relentlessly advocating for healthcare payers as they navigate complex and ever-changing drug cost management challenges. As a strategic partner, PSG empowers clients by providing industry-leading intelligence and technologies to improve clinical outcomes and realize billions of dollars in drug cost savings for clients every year.

Alexandra Morrison
anthonyBarnum Public Relations
alexandra.morrison@anthonybarnum.com
(214) 604-9658