Cell, Gene And Specialty Drug Costs Intensify For Health Plans

Specialty drugs are an increasing worry for health plans and employers as new and innovative therapies enter the U.S. market and patients flock to them, a new analysis shows.

Two in five health plans, or 43%, ranked management of specialty drug costs as their top goal ahead of managing the total cost of care at 41%, according to a report released Monday at Asembia ASX26 in Las Vegas by Pharmaceutical Strategies Group (PSG). The analysis was based on responses from 228 health benefits executives from health plans, employers and unions.

“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.”

Specialty drugs already account for well more than half of the total prescription spending any health plan, employer or government health program manages. And employer clients tell benefits consultants specialty costs easily account for 60% or more of their total drug spending, particularly as more Americans flock to anti-obesity GLP-1 medicines, prescriptions hailed for their ability to help people lose weight.

Now comes the annual 2026 trends in specialty drugs benefits PSG report at a time there are a parade of new cell and gene therapies hitting the market. PSG’s report said these treatments can prevent or treat a disease by “adding, replacing or turning off genes.”

But these therapies have emerged as a major concern with 85% of health plans and 71% of employers expecting these therapies to create “moderate” or “major financial challenges in the next few years,” the PSG report said.

“These innovative therapies carry heavy price tags (e.g., a treatment for acute lymphoblastic leukemia at $475,000 and a treatment for hemophilia B at $3,500,000),” PSG’s report said. “With novel cell and gene therapies (CGTs) entering the market and expanded indications for existing therapies receiving approval every year, payers may have concerns about the affordability of these therapies and their risk for a CGT claim.”

“While (cell and gene therapies) 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.”

Many employers and health plans are slow to adopt new ways of managing the cost of specialty drugs. Such medicines are more complicated than pills and capsules picked up at the corner drugstore and often require specialized administration, refrigeration, packaging and patient instructions, which can add to their costs and complexity in how they are paid for, analysts say.

Take oncology, for example, where “site of care” programs designed to shift patients from higher cost locations where drugs administered like outpatient hospitals to home infusion or physician offices are seldom used. PSG’s survey showed just 9% of respondents say they currently use a site of care strategy in oncology. But nearly 60% are “moderately” or “very willing” to do so, PSG’s report said.

“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.”