Kristen Reimers, RPh Sr. Vice President, Specialty Clinical Solutions
The 2026 Medical Pharmacy Trend Report: Part 1 - Payer Survey includes research data obtained through an industry-wide survey of health plan executives conducted in February 2026. Following data collection, the results were validated, aggregated and analyzed for reporting. This information was used to deliver a comprehensive view of payer insights of topics related to specialty drugs and management strategies.
Introduction
In the 2026 edition of the payer survey, we present insights from executives from 57 health plans covering 246 million lives. All U.S. regions are represented, with many plans operating across regions. Regional plans (23) provide a plurality with national plans (20), which is a useful lens for interpreting management sophistication and operational constraints. State/ local health plans (14) made up the remainder of the plans responding to the survey. Where applicable throughout the report, we will call out major differences in responses based on plan type. Read on for valuable insights on gene therapy, oncology, integrated specialty management and other industry hot topics.
GEOGRAPHIC DISPERSION OF LIVES
Hot topics
Our latest survey dives into the hottest trends shaping the future of managed care. From the transformative role of AI in pharmacy— where plans are exploring innovative ways to harness its potential while maintaining clinical precision and regulatory compliance—to the ripple effects of the 2026 expiration of Affordable Care Act (ACA) subsidies, we uncover how these changes are impacting plan enrollments and reshaping the healthcare landscape. We also explored regulatory readiness, focusing on how prepared plans are for the Centers for Medicare & Medicaid Services’ (CMS) transition to Maximum Fair Price (MFP)— influenced reimbursement for Part B drugs beginning in 2028—a shift expected to be a significant strategic consideration in the years ahead. In addition, we asked respondents to identify the single biggest challenge or concern their organization faces related to physician-administered medical benefit drugs.
7 Fraud, waste and abuse (FWA) detection and monitoring
IMPLEMENTING OR PILOTING AI-ENABLED PRIOR AUTHORIZATION FOR MEDICAL BENEFIT DRUGS
% of payers (N=40)
48% CONSIDERING
28% PILOTING OR IN DEVELOPMENT
6% YES, FULLY IMPLEMENTED
18% NO CURRENT PLANS
Membership and regulatory
PLAN PREPAREDNESS FOR CMS’S TRANSITION TO MFP-INFLUENCED
REIMBURSEMENT FOR PART B DRUGS
% of payers (N=51, Medicare plans only)
FULLY PREPARED
MODERATELY PREPARED
MINIMALLY PREPARED NOT PREPARED/UNSURE
PLAN ENROLLMENT CHANGES FROM 2025 TO 2026
TOP BENEFIT MANAGEMENT CONCERNS AND CHALLENGES
Site of care
Patient outcomes
Prior authorization
Financial risk
Payment delays
Formulary preferred drugs
Data monitoring Hospital markup
Provider contracted rates
Fee schedules White-bagging
MEMBERSHIP SHIFTS IN EXCHANGE PLANS
An equal percentage of plans saw increase or decrease in membership. 25% 25%
Gene therapy
Coverage journey
Gene therapy continues to be a top concern for payers. In our survey, 18 of 57 respondents (32%) were unaware of gene therapy management strategies at their organization. For the remaining 39 plans covering gene therapy, 95% cover some or all FDA-approved gene therapy products. National plans were far more likely to cover all approved gene therapy products, whereas regional and state/local plans were more likely to exclude some gene therapy products as investigational/experimental drugs. Most plans where gene therapy is excluded did allow a medical necessity exception review when requested.
Cover all FDA-approved gene therapies
33%
Cover some gene therapies
5%
Exclude all gene therapies
60% of payers report that greater than half of approved members ultimately receive gene therapy after approved authorization.
82% of those receiving gene therapy are treated within six months of authorization.
54% of plans use multiple methods to identify candidates for gene therapy.
IDENTIFYING CANDIDATES FOR GENE THERAPY CLAIMS
RECEIVING NOTIFICATION WHEN A MEMBER GETS GENE THERAPY AFTER TREATMENT IS AUTHORIZED
% of payers (N=39)
# of payers (N=39, multiple answers allowed) 72%
25 Proactive claims review
Challenges and strategies
Gene therapy provides treatment opportunities for patients with rare and complex diseases, albeit with a high price tag. Payers’ top concerns are managing the financial impact of these high-cost therapies and monitoring outcomes to ensure clinical efficacy. In our survey, there were no differences in plan type (national versus regional versus state/ local) for those plans that do not track clinical outcomes. Plans cite tracking outcomes across plan/coverage and interfacing with providers to receive clinical information as the biggest barriers to outcomes tracking. From a patient perspective, the gene therapy journey can be long, often involving prior authorization and financial assistance application processing, manufacturing and administration wait times, as well as the need for caregiver support and the administration of supportive therapies. There is no consensus among plans as to where the most significant delays are in the patient journey. As such, plans have implemented a variety of strategies to improve care for their members.
STRATEGIES FOR MONITORING GENE THERAPY OUTCOMES % of payers (N=25)
INTERNAL AND EXTERNAL TRACKING
INTERNAL CLAIMS DATA
MEDICAL RECORDS/ PROVIDER COMMUNICATIONS
CLAIMS AND MEDICAL RECORDS/PROVIDER COMMUNICATIONS
EXTERNAL VENDOR
64% of plans track gene therapy outcomes.
Oncology
CAR T-cell therapy
In 2025, the FDA removed Risk Evaluation and Mitigation Strategies (REMS) requirements for chimeric antigen receptor (CAR) T-cell therapy, which is anticipated to improve access by eliminating the requirement for centers to be specially certified. To understand organizational decision-making around CAR T- cell therapy, we gathered executive perspectives on current strategies. Forty-seven percent of plans report they have seen CAR T-cell therapy shifting to an outpatient site of service; however, the majority of these plans are seeing less than half of their total CAR T-cell cases moving to outpatient settings. Another development expanded approvals for CAR T-cell therapy to allow for use in earlier lines of therapy, which could impact utilization and spend.
CAR T-CELL STRATEGY CHANGES ALLOWING USE
EARLIER IN TREATMENT
# of payers (N=57, multiple answers allowed)
Clinical criteria updated 16 Prefer products with expanded indication 14 No changes to management strategy 3 Unsure
CAR T-CELL THERAPY SHIFTING TO OUTPATIENT SETTING
of payers (N=57)
CAR T: STRATEGIES FOR MONITORING OUTCOMES
% of payers (N=35)
Claims and medical records/provider communications
CAR T: LARGEST BARRIER FOR OUTCOMES TRACKING
% of payers (N=57)
33% Provider communication
26% Tracking across plans
25% Lack of staff/ infrastructure
14% Clinical criteria updated
2%
General oncology management strategies
An emerging trend in oncology is the approval of subcutaneous (SQ) forms of medications that were previously only available as intravenous (IV) formulations (e.g., Opdivo Qvantig and Keytruda Qlex). The vast majority of plans (89%) have implemented coverage strategies for these new formulations. Shifts in utilization from IV to SQ formulations are occurring at the same rate regardless if it is a new start or continuation of therapy, or if the SQ medication is a part of a single-drug or multidrug regimen. Most of these SQ formulations are still provider-administered and require monitoring for toxicities the same as the IV formulations. Plans are overwhelmingly interested (93%) in monitoring oncology treatment via reports that span across pharmacy and medical benefits.
TOP CONCERNS WITH SQ FORMULATIONS % of payers (N=57)
COST
COMPARATIVE EFFICACY TO IV FORM
REGIMEN CONTAINS SQ AND IV PRODUCTS
PATIENT SATISFACTION
UNSURE
DELAYED BIOSIMILAR CONVERSION
56% of plans are seeing a shift to SQ formulations of oncology drugs.
RADIOPHARMACEUTICAL MANAGEMENT STRATEGIES
63% of plans have or are implementing regimen-based reviews; 18% of plans do not have but would prefer this type of review.
44% of plans manage radiopharmaceuticals for both diagnostic and treatment purposes; 35% manage for treatment only.
46 Prior authorization
36 Post-service claim edits/dose optimization
31 Fee schedule # of payers (N=49, multiple answers allowed)
TOP CHALLENGE TO PERFORMING ONCOLOGY REGIMEN-BASED PRIOR AUTHORIZATION REVIEWS
% of payers (N=46)
39%
26% 22% 9% 4%
Medical and pharmacy benefits managed by different groups
Provider communication/access to chart notes No current challenges
Solution not offered by current vendor/benefit manager Unsure
Biosimilars
Biosimilars represent the most mature area of management across the survey. Nearly all participating plans report having biosimilar management strategies in place, reflecting the strongest consensus observed in this year’s results. Although cost reduction is the primary driver of these strategies, improving affordability and financial accessibility for members remains a central consideration. As additional biosimilars— particularly for specialty drugs—enter the market, quantifying savings impact will be an important area to explore in future survey editions.
56 out of 57 plans indicated they have a strategy for biosimilars on the medical benefit.
of payers (N=56)
REASON FOR BIOSIMILAR STRATEGY % of payers (N=57)
BETTER REIMBURSEMENT RATES FOR BIOSIMILARS
BIOSIMILAR COVERAGE STRATEGIES
# of payers (N=56, multiple answers allowed)
31 Reference product requires step therapy through biosimilar(s)
26 Reference product and biosimilar(s) covered equally
5 Biosimilar(s) require step therapy through reference product
4 Other: Rebate dependent
1 Unsure
Integrated specialty
“Integrated specialty management” is defined in this report as integrating claims review and strategies across medical and pharmacy benefits. Having an integrated lens to benefit management provides plans a holistic view of the treatment their members receive and allows for the most clinically appropriate, costeffective management of specialty medications. Health plan leaders described integrated specialty management through four consistent themes—cost transparency, holistic care, improved patient outcomes, and clinical- operational alignment. Together, these responses underscore the importance of integration. The quotes on the next page reflect payer perspectives in their own words.
ALLOW WHITE-BAGGING
%
of payers (N=57)
“White-bagging” means the cost of medical specialty drugs is billed on the pharmacy benefit then shipped to the provider’s office for administration.
Split medical and pharmacy benefits administration is the top duplicateclaims challenge for 71% of plans.
HOLISTIC APPROACH
Q: A:
How do you define “integrated specialty management”?
COST TRANSPARENCY
“Managing cost at a therapeutic level rather than individual treatment regimen.”
“Getting cost transparency related to specialty drugs and value-based care for all patients.”
IMPROVING PATIENT CARE
“Combining the treatment planning and pharmacy benefits for patient safety and to get better outcomes.”
“Managing therapies and care together to ensure that patients receive effective treatment at [a] lower cost.”
“A strategic approach designed to coordinate the complex clinical, financial and administrative aspects of specialty drugs and high-touch member care.”
“Managing across the entire member-provided benefit along with managing holistic patient care tied to the specialty condition.”
ALIGNING CLINICAL AND OPERATION SYSTEMS
“It is a management [that] connects clinical and operational [fields] together.”
“Combining pharmacy, physicians and case management in one organized platform, which would be beneficial for the patients and their health.”
Part 1 - Payer Survey
This report explores real-world payer survey insights on hot topics and emerging strategies, revealing where plans are investing, where barriers persist, and what’s shaping decision-making.
Part 2 - Drug Overview: Available this summer
This report provides a high-level analysis of key drug trends, highlighting utilization patterns and the clinical and financial factors shaping medical pharmacy spend across commercial, Medicare, and Medicaid populations.
Comprehensive Report: Available this fall
The complete Medical Pharmacy Trend Report will include the content above plus expert insights on PMPM trends and spend, in-depth analysis of top spend disease categories, and integrated benefit trends for select therapy categories.
