Specialty Drug Costs and Complexity Steadily Rising Since 2025

For a majority of payers throughout health care, managing complex costs and implementing useful strategies for beneficiaries remain top priorities in the specialty drug arena, according to a recent webinar conducted by the Pharmaceutical Strategies Group (PSG).¹

“This year’s report highlights a market at an inflection point, with payers increasingly challenged to balance the potential benefits of groundbreaking treatments with the escalating cost of care—a tension that’s driving health plans and employers to rethink their strategies to manage the specialty drug benefit,” wrote the authors of PSG’s Trends in Specialty Drug Benefits Report.² “By examining these topics, we aim to shed light on how the landscape is evolving in response to payers’ priorities and pain points.”

For the modern pharmacist, this shift represents a transformation in how medications are managed, distributed, and perceived by the broader health care system.

READ MORE: Advanced Therapies Are Expanding Patient Access in Specialty Pharmacy | Asembia AXS26

As specialty drugs are projected to account for more than 60% of total pharmacy spending in 2026, despite representing fewer than 5% of total prescriptions, the pressure on pharmacy professionals to deliver clinical value while managing financial volatility has never been higher.³

This surge in spending is driven by a convergence of innovative but expensive therapies, including the expansion of glucagon-like peptide-1 (GLP-1) medications into chronic condition management for weight loss and metabolic health. The financial impact is being felt acutely by patients, as total out-of-pocket costs hit a record $110 billion in 2025.^3,4

Data from the Academy of Managed Care Pharmacy indicates that oncology and rare disease innovations now define over 85% of the drug development pipeline, moving the industry toward biomarker-driven, precision medicine. Although these breakthroughs improve survival rates and tolerability, they introduce significant financial risk. A single therapy claim can exceed $1 million, often catching self-funded employers off guard.^3,5

In this environment of rising complexity, the role of the specialty pharmacist is under significant scrutiny. Payers are increasingly viewing specialty services through the lens of “commoditization,” with many questioning if these pharmacies provide meaningful care.²

Only 1 in 5 payers rate the clinical support provided by their specialty pharmacy network as very good. On a 10-point scale, payers gave a mean rating of 5.9 regarding whether specialty pharmacies differ in the care they offer. This perception stands in contrast to the specialized expertise required to manage these drugs, which often involve unique administration routes, special handling, and intense patient education on side effects and adherence.^2,6

Specialty pharmacists remain pivotal advisors, helping patients avoid unnecessary hospitalizations and navigating the administrative maze of prior authorizations.⁶

The administrative burden remains a constant for pharmacists, as prior authorization is now nearly universal, utilized by 96% of plans. Despite clinical experts noting that some annual renewals for lifelong therapies may lack utility, there is little support among payers for relaxing these requirements, with 1 in 4 stating they do not support relaxation for any drug class.^1,2

This tension is visible at the pharmacy counter, where members face average monthly claims exceeding $5000. In some cases, patients are expressing frustration when pharmacy benefit manager-owned specialty pharmacies charge thousands of dollars more for generics than local centers or cash-pay discount programs.¹

Relief may arrive via a massive patent cliff, with $43 billion in brand sales exposed to generic competition in 2026. Biosimilars are also gaining traction, with utilization reaching 36.7% as payers implement mandatory conversion strategies for patients already on branded biologics.^2,5

However, a potential biosimilar gap looms if competition fails to materialize for over 100 biologics losing exclusivity in the next decade. Simultaneously, pharmacists are adjusting to “white bagging,” where drugs administered by professionals are shifted from the medical to the pharmacy benefit—a strategy now used by over 40% of health plans.

Although 50 to 55 new medicines are expected to launch annually, nearly two-thirds of prescriptions for new drugs currently go unfilled in their first year. Pharmacists must remain the essential link in the chain, ensuring that innovation leads to actual therapy rather than an abandoned prescription due to cost or complexity.^2,4,6

“All in all, I think the market itself has been a little tricky,” concluded Renee Rayburg, RPh, vice president of clinical strategy with PSG, during her organization’s webinar.¹ “I think we're still working through how to optimize those savings from it.”

READ MORE: Asembia Specialty Pharmacy Summit 2026

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REFERENCES

1. Rayburg R, Lee M, Gregg R. 2026 trends in specialty drug benefits report webinar. Pharmaceutical Strategies Group. May 7, 2026. Accessed May 11, 2026. https://www.psgconsults.com/webinar/2026-trends-in-specialty-drug-benefits-report-webinar/

2. Lee M, Lonergan M, Gregg R, et al. Trends in specialty drug benefits report. Pharmaceutical Strategies Group. May 2026. Accessed May 11, 2026. https://link.psgconsults.com/2026_Trends_in_Specialty_Drug_Benefits_Report

3. The 2026 specialty drug surge: what employers need to prepare for. Insurica. 2026. Accessed May 11, 2026. https://insurica.com/blog/2026-specialty-drug-surge/

4. U.S. medicine use trends 2026. IQVIA. April 28, 2026. Accessed May 11, 2026. https://www.iqvia.com/insights/the-iqvia-institute/reports-and-publications/reports/us-medicine-use-trends-2026

5. McCormick B. AMCP 2026 spotlights new era for specialty drug market. AJMC. April 23, 2026. Accessed May 11, 2026. https://www.ajmc.com/view/amcp-2026-spotlights-new-era-for-specialty-drug-market

6. Six reasons the specialty pharmacist role is increasingly important. Orsini. July 17, 2023. Accessed May 11, 2026. https://www.orsini.com/six-reasons-the-specialty-pharmacist-role-is-increasingly-important/