You don't get a warning when a specialty claim lands. It just shows up. And the drugs heading toward your plan in 2027 aren't small-dollar items.
Specialty pharmacy dispensing revenue hit $293.4 billion in 2025, a 9.6% jump over the prior year, according to Drug Channels Institute. That's not a blip. That's a structural shift in what employer health plans cost.
The hard part? Most of that spend comes from a tiny slice of your workforce.
How Much of Your Drug Spend Is Specialty?
More than half. For the first time, specialty drugs now exceed 50% of total pharmacy spend among commercial plans. Evernorth pegged it at 51% in 2025, with per-member per-year specialty spend hitting $816.
That number is projected to reach 60% by 2027.
Here's the math that should stop you cold. About 2% of your members use specialty medications. Those members drive more than half your total drug spend. The Commonwealth Fund puts the average annual cost to cover a specialty patient's drugs at roughly $38,000. For a non-specialty patient? $492. That's a 77x difference.
You're designing a benefits program for hundreds of employees. But a handful of specialty claims can swing your renewal by double digits. Without a proactive formulary strategy, you're reacting to costs instead of managing them.
So what's actually coming?
What's in the 2027 Specialty Drug Pipeline?
The FDA approved 58 novel therapies in 2025. Seventy-two percent of them were classified as specialty drugs. More than half carried orphan designation. And specialty medications will account for more than 80% of expected 2026 approvals, according to coverage from AMCP 2026.
The categories to watch: oncology, immunology, cell and gene therapies, and GLP-1s.
Oncology alone accounts for 45% of drugs currently in development, with 23 near-term therapies spanning solid tumors and hematologic malignancies. Globally, oncology drug spending reached $250 billion in 2024. Immunology followed at $198 billion. Anti-diabetics, including GLP-1s, came in at $138 billion. Those three categories represented over 70% of the innovative biologic market, per IQVIA Institute.
Per-member-per-month oncology spend alone is projected to roughly double between 2025 and 2027.
Orphan drugs now make up 40% of the pipeline. Precision oncology and rare disease therapies exceed 85% of all development activity. These aren't mass-market drugs. They're narrow-indication, high-cost treatments that land on a single employee and blow through your stop-loss.
What Will Cell and Gene Therapies Cost Your Plan?
This is the category that breaks the math on traditional plan design.
Casgevy, a gene therapy for sickle cell disease from Vertex, costs $2.2 million per patient. Lyfgenia, from bluebird bio, costs $3.1 million. One employee. One claim. Seven figures.
The pipeline keeps growing. CAR-T therapies for blood cancers. Gene replacement for rare diseases. These aren't theoretical. They're FDA-approved and heading to your formulary.
If your stop-loss carrier is already raising rates 15%, a single gene therapy claim could push your next renewal into a different tier entirely. That's why stop-loss carriers are pricing gene therapy risk separately. And it's why you need to know whether your plan has a gene therapy management strategy or just a gap.
How Are GLP-1 Drugs Changing Employer Pharmacy Spend?
Fast. GLP-1 drugs averaged 10.5% of total annual employer claims in 2025, up from 8.9% in 2024 and 6.9% in 2023, according to SHRM. Twenty-nine percent of employers reported GLP-1 costs exceeding 15% of annual claims.
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That trend isn't slowing. New GLP-1 indications for MASH (metabolic liver disease) could see approvals between 2027 and 2029. Survodutide from Boehringer Ingelheim may get an FDA decision as early as 2027.
There's a potential offset. Generics for liraglutide (Saxenda) and dulaglutide (Trulicity) could hit the market in 2027, which would bring unit costs down. But demand is growing faster than costs are falling.
Biosimilars saved employers and plans $20.2 billion in 2024 alone, according to the Association for Accessible Medicines and IQVIA. Cumulative savings since 2015 have reached $56.2 billion. Over the next five years, roughly $100 billion in specialty drug spend will face biosimilar or generic competition.
The biggest opportunities right now:
Humira: Nine-plus biosimilars on the market. Humira's U.S. sales fell 37.6% in 2024 to $8.99 billion. If your plan is still paying brand rates, that's a red flag.
Stelara: Biosimilar competition entered 2024 and 2025. Expected net prices are 80% lower than Stelara's list price.
Keytruda and Opdivo: Biosimilar equivalents aren't expected until closer to 2030. These remain full-price exposures for now.
Major PBMs have started steering toward biosimilars aggressively in 2025 and 2026. But steering only works if your contract requires it. Check whether your PBM has a biosimilar-first policy, and whether you're actually seeing the savings flow through. Your rebate guarantees may protect the PBM, not your plan.
This is also why the carve-out vs. carve-in decision matters. A carved-out pharmacy benefit gives you more control over biosimilar adoption and formulary design.
What Does the CAA of 2026 Mean for Specialty Drug Costs?
The Consolidated Appropriations Act of 2026, signed February 3, includes the most significant PBM reform in decades. The key provisions:
100% rebate pass-through to employer health plans. Mandatory.
PBM compensation must be flat fees, not tied to drug price.
New transparency and reporting requirements for PBMs.
This directly changes how specialty drug savings reach your plan. Before, your PBM could keep a slice of every rebate and call it "administrative fees." Now they can't.
If you're renewing a PBM contract in the next 12 months, these are the terms worth renegotiating. And if your PBM is dragging its feet on compliance, ask why. The Benefits Blake Compliance Calendar tracks 72 federal requirements, including the new CAA mandates, so nothing falls through the cracks.
What Should Self-Funded Employers Do Now?
Specialty drug exposure isn't something you can budget for reactively. By the time a $2 million gene therapy claim hits, it's too late to negotiate.
Here's a short list.
Run a mid-year claims review. Know your current specialty spend by category before stop-loss renewal season starts. If you don't know your numbers, your carrier does.
Audit your PBM contract. Are biosimilar savings flowing through? Are rebates being passed at 100%? Is your formulary optimized for the drugs your members actually use? If you're not sure, check whether your PBM's rebate structure has hidden margin.
Model your five-year trajectory. Specialty trend is running 9-10% annually. A 300-life plan that ignores it will overspend by hundreds of thousands over five years. The 5-Year Benefits Blueprint projects exactly where you'll land.
Ask about gene therapy coverage. Does your stop-loss policy cover it? Is there a separate rider? What's the laser threshold? These are questions for your broker, and you should be asking them now.
Simplify your stack. The more vendors touching your pharmacy benefit, the harder it is to track where money goes. The Benefits Control System scores your current setup and flags where complexity is costing you.
The specialty drug pipeline isn't slowing down. The only question is whether your plan is ready for what's coming or just hoping it doesn't land on your roster.
