Survey: Tactics to Manage Specialty Drug Trends Remain Payer Priority
by Angela Maas
Payers continue to rank managing specialty drug costs, particularly for expanded indications and new therapies, as their top concern for these agents, according to the 2026 Trends in Specialty Drug Benefits Report from Pharmaceutical Strategies Group (PSG), an EPIC company.
Published in April, the report was co-sponsored by Genentech, a member of the Roche Group, and was fielded online in September and October 2025. Respondents consisted of benefits leaders from 228 employers, union/Taft-Hartley funds and health plans with a median of 12,000 covered lives.
Respondents cited managing overall specialty trend/specialty drug costs and managing the total cost of care as their two top specialty drug management goals. During a May 7 webinar, Morgan Lee, Ph.D., vice president of research and marketing at PSG, clarified that respondents ranked several goals, and lower-ranked goals “are simply not prioritized as strongly as” higher-ranked goals, but that “their placement doesn’t mean they’re unimportant to plans, and strategies that address those top goals can also in some cases align with achieving other goals.”
Among the challenges related to managing specialty drugs, a strategy specific to coverage of expanded indications and new specialty drugs — a new option for respondents to the most recent survey — was ranked No. 1 in mean rating. The challenges, explained Lee, align with what PSG sees among its clients and in the broader market.
“Given the complexities of the current drug landscape, none of this is really surprising,” asserted Renee Rayburg, R.Ph., vice president of specialty clinical consulting at PSG, during the webinar. While specialty drugs have represented at least half of FDA-approved novel new therapies over the last decade, in 2025, they made up 76% of those new drug approvals, she noted.
Almost Three-Quarters Have Medical Drug Formularies
While specialty drugs that are adjudicated under the pharmacy benefit have long been subjected to formularies, 72% of all respondents said they had implemented a medical drug formulary, said Lee. “Plans must also increasingly consider their strategy across both pharmacy and medical benefits,” she stated. Almost one-third of respondents said they focused on optimizing their specialty drug formulary across both benefits to a great extent, while another 37% said this was a moderate focus. And 57% of the total respondents said they had processes in place to manage the formulary across the pharmacy and medical benefits.
According to Rayburg, aligned cross-benefit optimization tactics include aligned coverage rules, consistent biosimilar preferences and unified step therapy. She noted that manufacturers have been increasingly focused on “dosage forms that allow for easier patient administration or/and a better patient experience,” which in turn has made it more challenging for payers to manage across the benefits.
Common areas for this include inflammatory conditions, asthma and oncology, said Rayburg, who noted that some inflammatory agents require an initial dose via infusion by a medical professional and then maintenance dosing through subcutaneous self-administration. “So access to integrated data can be really valuable here, as having that visibility into the plan costs in each benefit is helpful especially when making these benefit coverage decisions,” she emphasized.
Only 20% of respondents — 13% of employers and 35% of health plans — said they participated in value-based contracting. This, however, was an increase from the 8% of respondents who had such contracts when the question was last asked two years ago.
Are Specialty Pharmacies Really Special?
A new question in the most recent survey found that 63% of respondents had an exclusive specialty pharmacy network. Still, respondents differed in how they viewed specialty pharmacies and the care they provide, noted Lee. Based on the rating, “it seems that the answer to whether specialty pharmacies are truly special in today’s environment is a ‘maybe’ for the majority of plans,” she said.
Based on her experience, Rayburg said that “plans have higher expectations for the service levels, especially around the specialty drug expertise, enhanced patient care from the specialty pharmacies as well. But plans struggle with these higher expectations and suboptimal delivery of those expectations, especially with the PBM-owned specialty pharmacies, where they experience some additional challenges.”
Examples are selective inventory, particularly with specialty generics and biosimilars, and unsubstantiated overrides, with patients getting more fills annually than they need, leading to overutilization, said Rayburg. Inadequate service levels are an issue as well.
Almost all respondents reported receiving specialty drug rebates under the pharmacy benefit, but only slightly more than half total — 43% of employers and 70% of health plans — said they receive them under the medical benefit. Among those receiving medical drug rebates, most said that maximizing those rebates is at least a moderate priority.
In terms of alternatives to receiving rebates, a mean of 3.5 respondents out of five cited preferring drugs that are lower priced but do not have rebates. Respondents who said they would accept lower rebate guarantees in exchange for the ability to implement more utilization management strategies rose year over year from a median of 2.7 to 3.0.
“Plans that want to implement more restrictive UM controls may be faced with accepting lower rebates in exchange,” noted Lee based on a follow-up question. “In our experience, payers often benefit most when they’re optimizing their clinical management over focusing on maximizing their rebates.”
But moving away from dependency on rebates is “very complicated,” maintained Rayburg, as payers seek “other levers to pull” in order to manage their specialty drug spend. This, however, may not be as straightforward as it seems.
“Sometimes the decisions become less about the actual drug price per claim…, and these consequences often impact the rebate guarantees that financially are worth a lot to payers. This occurs when there is interest in making UM more stringent,” such as requiring documentation for certain diagnoses or mandating that members must first step through a lower-cost drug. Taking such steps may lower the rebate guarantee or negate it entirely, she pointed out.
“But in addition, sometimes payers are asked to loosen criteria in exchange for a higher rebate guarantee, but in our experience, doing that really has only provided short-term gain,” said Rayburg. “I think there is a lot of value in controlling utilization, and sometimes it is just worth taking the time to kind of evaluate the process and the complicatedness of it all to see financially where you have more to gain.”
Download the new report to learn more about other trends.