According to the National Alliance of Healthcare Purchaser Coalitions’ 2026 Pulse of the Purchaser survey, 60% of employers are currently reviewing pharmacy claims billed through the medical benefit. Another 27% are considering it. Only 13% aren’t thinking about it at all.
That’s a meaningful shift. Reviewing drugs billed through the medical benefit is no longer a novel idea being introduced to employers; it’s something the majority are already doing in some form.
What the data doesn’t show is what happens after the review. And that’s where a gap opens up.
PSG’s 2026 Trends in Specialty Drug Benefits Report surveyed a different population: employers, health plans, and union/Taft-Hartley plans, and asked specifically about rebate receipt. 93% of employers receive specialty drug rebates under the pharmacy benefit. Under the medical benefit, that number drops to 43%.
Two separate surveys, two different questions. One shows most employers are reviewing the channel. The other shows fewer than half are capturing any rebate value from it.
Reviewing and capturing are not the same thing. The distance between them is where most of the work isn’t happening.
The standard cost-containment toolkit that advisors and consultants bring to self-funded employers is well-documented and pharmacy-focused. PBM audits, formulary design, utilization management, biosimilar substitution, site-of-care programs, and reference-based pricing – the pharmacy benefit side has decades of developed infrastructure behind it. Pharmacy consultants understand PBM contract leverage points, know how to run an RFP, and can benchmark rebate guarantees against market rates.
The medical benefit side of specialty drug economics operates on different mechanics. Physician-administered drugs, infused biologics, oncology agents, and therapies given in clinical settings are billed as medical claims using J-codes, adjudicated through the TPA, and subject to manufacturer rebate programs that the PBM contract doesn’t govern. The relevant terms sit in the TPA agreement. Most advisor engagements are built around the PBM relationship, which means this channel falls outside the natural scope of a standard pharmacy engagement, not by oversight, but because the market built its expertise where the contracts were.
PSG’s data on why employers aren’t receiving medical benefit rebates is worth looking at directly. Of those not receiving them, 34% said the health plan captures the rebates but uses them to offset premiums rather than passing them through. 29% said the health plan doesn’t receive them at all. And 29% said they simply haven’t discussed it with their health plan or TPA.
Nearly a third of employers not receiving medical benefit rebates haven’t raised the question with anyone. The National Alliance’s finding that 60% are already reviewing the channel suggests the awareness is there. The PSG finding that only 43% are receiving rebates suggests the conversation about what to do with that review, specifically, whether manufacturer rebate programs are being pursued, largely isn’t happening.
For the advisors and consultants reading this, that 29% is a specific opening. Not a wholesale program change, not a new vendor relationship, a conversation about what rebate programs apply to the drugs already showing up in the medical benefit review the client is already doing.
For plan sponsors: if your medical benefit drug claims are being reviewed but your advisor hasn’t raised the rebate question, it’s worth putting on the agenda.
PSG’s data also shows the direction of travel. Among employers that do receive medical benefit rebates, emphasis on maximizing them rose from a mean of 2.5 to 2.8 on a four-point scale year-over-year. The interest is building. The employers who surface the question through a newsletter, a peer conversation, or an industry event are increasingly likely to bring it into their next advisor meeting.
The advisors who have already thought through the medical benefit rebate question- what drugs are eligible, where the terms live, what the process looks like- are better positioned for that conversation than those who haven’t.
Whether you’re an advisor thinking about how the medical benefit side fits into your current engagements, or an employer who has started asking this question — we’d like to hear how the conversation is going. Comment below.
Disclaimer: This newsletter references publicly available findings from the National Alliance of Healthcare Purchaser Coalitions’ 2026 Pulse of the Purchaser Survey and Pharmaceutical Strategies Group’s 2026 Trends in Specialty Drug Benefits Report. VativoRx is not affiliated with, endorsed by, or partnered with the National Alliance, PSG, or any co-sponsor or member coalition of either organization. Data points are cited objectively for informational purposes only. This newsletter does not constitute legal, regulatory, clinical, or financial advice. Readers should consult appropriate advisors regarding specific circumstances.