How payers are rethinking specialty drug benefits | Asembia AXS26 Summit

How payers are managing and covering specialty drug benefits is evolving, say leaders from Pharmaceutical Strategies Group (PSG), who presented highlights from PSG’s “2026 Trends in Specialty Drug Benefits Report” at Asembia’s AXS26 summit, held in Las Vegas from April 26 to April 30.

PSG’s research found that payers are paying closer attention to specialty drugs covered under the medical benefit, showing greater willingness to accept fewer rebates in exchange for stronger utilization management controls and reevaluating whether current pharmacy benefit management models are aligned with their best interests.

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.

In an interview ahead of the meeting, Renee Rayburg, RPh, vice president of clinical strategy at PSG, and Morgan Lee, Ph.D., vice president of research and marketing at PSG, discussed findings from the survey and the evolving landscape of specialty drug benefits, as well as current trends in and projections for the specialty drug benefit design.

Below is an excerpt from the conversation.

What challenges do payers face with specialty pharmacy?

Rayburg: Payers are challenged with the specialty drug pipeline, expanded indication pipeline and new products that have been approved. New this year in the survey was an option for respondents to rank their challenges. The strategy for covering expanded indications and specialty drugs has become really important because specialty drugs have dominated new drug approvals.

Over the past 10 years, specialty drugs have been at least 50% of new drug approvals, the novel drug approvals from the FDA. But in 2025, specialty drugs reached a high of 76% of the novel drugs that were approved. Specialty drugs are very high cost, based on some of our other reports, with an average of a $5,000 monthly cost per claim. Specialty is going to continue to increase in double-digit trends for our clients.

The science continues to advance. There are a lot of drugs in the pipeline, new and expanded indications for existing drugs. Dupixent, for example, was approved in 2017 for atopic dermatitis; it now has nine indications, including one for asthma. As a pharmacist, I find the science exciting.

Lee: These advances are incredible, and they are also putting a tremendous amount of pressure on payers as they work on how to create a sustainable strategy. That’s the beauty and the challenge of where we’re at right now. There are a tremendous number of advances, but that’s also brought a lot of complexity to the space. What we’re seeing payers do is really having to look at new strategies and different ways that they might think about their specialty benefit because of these changes.

How are players structuring their benefits in terms of utilization management, including prior authorization (PA)?

Lee: In terms of PA, we’ve been talking about the topic for a really long time, but this is our first year asking a question more specific to whether payers are supportive of changes that would include reducing or removing PA for some therapeutic classes. We found that they are also not supportive of just wholesale removal, and they recognize that prior authorization can provide value to them in some areas.

Another new question we asked this year was about their level of concern around unintended consequences of utilization management, such as PA, step therapy and other types of strategies. We looked at it by disease category. In oncology and multiple sclerosis, for example, there were much higher levels of concern about what impact [utilization management] might have compared with atopic dermatitis, where they were less concerned.

Rayburg: The process of PA is not perfect. I would even say it’s probably a little broken, but the survey respondents don’t seem ready to just do away with it.

We didn’t ask about AI [artificial intelligence] and PA, but there are vendors today that are trying to use AI to comb through the data and use AI or forms of it to make it easier to consolidate the data. AI can be a good tool that maybe could collect the electronic health record or notes from the charts and then diagnosis codes. There are companies doing that and looking into other information that supports the PA and the PA process. We made an intentional decision to leave it out of this survey because in a survey, it is very hard to establish what is truly meant when someone says they’re using the AI-enhanced tools.

This is the first year your survey looked at the role of the specialty pharmacy. What did you find?

Lee: There’s a lot of good conversation happening right now around the role of specialty pharmacies, about what they are providing and their essential role. We wanted to look into whether payers perceive that some specialty pharmacies differ from others in how they support patients.

There’s some differentiation perceived, but maybe not to the degree that some specialty pharmacies might have expected. About 1 in 3 of the health plans in our survey gave a rating on specialty pharmacies that leaned toward not seeing much differentiation there. It was a bit surprising.

Rayburg: Payers in general have higher expectations from specialty pharmacies when it comes to clinical expertise and enhanced patient care. They’re not seeing differences between them. It’s important to be aware of this because specialty pharmacies may not realize they’re being seen in that light.