Most health plans and TPAs have a rebate process for specialty drugs. What PSG’s just-released 2026 Trends in Specialty Drug Benefits Report makes clear, with hard survey data, is how incomplete that process typically is.
According to the report, 93% of surveyed organizations receive specialty drug rebates under the pharmacy benefit. Just 51% receive them under the medical benefit. That 42-point gap represents one of the most consistent and underaddressed structural mismatches in specialty drug cost management today.
Two Benefits. Two Very Different Rebate Realities.
The gap isn’t a mystery. PSG explains it directly: while PBMs manage formularies under the pharmacy benefit, according to the 2026 report, they are considerably less involved in managing drugs covered under the medical benefit. Specialty drugs administered in physician offices, infusion centers, and outpatient settings are billed as medical claims, a different channel, a different billing structure, and a different rebate process than what PBM contracts are built to handle.
The result is a structural asymmetry. Organizations that have pharmacy rebate processes in place have built those processes around the PBM relationship. The medical benefit equivalent, manufacturer rebates on physician-administered specialty therapies, requires a separate operational approach that most organizations haven’t built.
PSG’s data shows where that plays out most acutely. Health plans fare better than employers: 70% of health plans in the survey receive medical benefit rebates, compared to just 43% of employers. But even among health plans, nearly a third are leaving this rebate channel unworked.
Why Employers Often Don’t Receive Medical Rebates — And Why That’s Changing
For employers that don’t receive medical benefit rebates, PSG’s report asked why. The answers were nearly evenly split among three causes: the health plan uses the rebates to offset premiums rather than passing them through, the health plan doesn’t receive the rebates at all, so it can’t pass them along, and, notably, the employer simply hasn’t discussed the topic with their health plan.
That third answer signals something important. For a meaningful share of organizations, the gap isn’t a structural impossibility. It’s an open conversation.
At the same time, PSG’s data shows awareness is rising. Among organizations that do receive medical drug rebates, emphasis on maximizing them increased from a mean of 2.5 to 3.0 on a four-point scale year-over-year. That’s a directional shift that suggests the medical benefit rebate conversation is moving up the priority stack, not as a niche topic, but as a cost management lever with real financial weight.
The Biosimilar Layer
Biosimilar adoption adds another dimension to this picture. PSG’s report notes biosimilar utilization grew from 27.3% in 2023 to 36.7% overall in 2024, a meaningful increase driven by PBM-led strategies and new market entrants across high-utilization drug classes.
But the data reveals a gap in how that strategy is applied across benefits. Health plans are far more likely than employers to apply biosimilar strategies to both pharmacy and medical benefit drugs, 56% of health plans versus 18% of employers use a lowest net cost biosimilar strategy across both channels. That divergence means many organizations are navigating biosimilar transitions primarily on the pharmacy side, while the medical benefit, where a substantial portion of high-cost biologics are administered, operates without an equivalent framework in place.
What This Means by Audience
For mid-market and regional health plans, the 70% medical rebate receipt rate in PSG’s survey is the more relevant benchmark. Thirty percent of health plans do not receive medical benefit rebates at all, and among those that do, emphasis on maximizing them has historically been lower than on the pharmacy side. As cross-benefit specialty formulary optimization becomes a more active priority (PSG found two in three payers are focusing on it to a moderate or great extent), the medical rebate process is no longer a secondary consideration.
For TPAs and self-funded employers, the picture is more stark. Under half of employers in PSG’s survey receive medical benefit rebates. And for those that don’t, a significant share haven’t even raised the question with their health plan. For TPAs serving these groups, the medical benefit rebate conversation is a gap in the current value story, one that’s increasingly visible as specialty costs rise and clients ask harder questions about where cost offsets are working.
What to Watch
The cross-benefit optimization trend is real and accelerating. PSG found the majority of payers are focusing on ensuring their specialty formulary is optimized across pharmacy and medical benefits. For organizations that haven’t established a medical benefit rebate process, that trend puts them on the trailing edge of where the market is moving.
The reasons employers don’t receive medical rebates point to solvable problems. A plan using rebates to offset premiums, a conversation that hasn’t happened, a process that hasn’t been built, these aren’t structural barriers. There are operational gaps with operational solutions.
Biosimilar strategy asymmetry will grow more visible. As biosimilar adoption continues to accelerate, organizations applying those strategies only to the pharmacy channel will find the medical benefit side of the picture increasingly hard to ignore.
The gap between pharmacy and medical rebate receipt is documented and growing harder to defend. PSG’s survey data gives organizations and their advisors a credible benchmark. A 42-point gap between pharmacy and medical rebate receipt, published by an independent research firm, is the kind of number that shows up in board discussions and client conversations.
The Practical Starting Point
PSG’s 2026 data doesn’t just describe the gap; it identifies where it lives. For health plans, the question is whether the 30% not receiving medical rebates have assessed what’s available or simply haven’t built the process. For employers and the TPAs serving them, the more immediate question is whether the medical benefit rebate conversation has happened at all.
The pharmacy side of specialty drug rebate management has a mature, well-understood infrastructure. The medical benefit side, by PSG’s own data, does not. Closing that gap starts with recognizing it exists, and this year’s report makes that case in numbers.
PSG’s 2026 Trends in Specialty Drug Benefits Report was published this spring. What’s your organization’s current approach to medical benefit rebates — and does it match what this data describes? Share your perspective in the comments.
Disclaimer: This newsletter references publicly available findings from Pharmaceutical Strategies Group’s 2026 Trends in Specialty Drug Benefits Report. VativoRx is not affiliated with, endorsed by, or partnered with PSG or any co-sponsor of that report. Data points are cited objectively for informational purposes only. This newsletter does not constitute legal, regulatory, clinical, or financial advice. Rebate eligibility and outcomes vary by organization, program terms, payer contracts, and applicable laws and regulations. Readers should consult their legal, compliance, and financial advisors regarding specific circumstances.
