Two surveys released in August put numbers on a shift that has been building for years. Business Group on Health’s 2027 Employer Healthcare Strategy Survey of 127 employers representing 11 million covered lives found that 32% will offer transparent or next-generation PBM arrangements in 2027, and another 47% are considering the move for 2028 or 2029, as reported by MedCity News. The National Alliance of Healthcare Purchaser Coalitions’ 2026 Pulse of the Purchaser Survey found the share of employers using one of the three largest PBMs fell from 63.4% in 2025 to 54.3% in 2026 in a single year.
That’s not a trend line. It’s a decision being made at scale, in real time, heading into 2027 and 2028 renewals.
What’s Driving It
The Consolidated Appropriations Act of 2026, signed February 3, 2026, requires PBMs to pass through 100% of rebates, fees, discounts, and other manufacturer payments to ERISA group health plans — effective for plan years beginning August 3, 2028. The regulatory direction and the employer market movement are reinforcing each other. PBMs are adjusting their pricing models. Employers aren’t waiting for 2028 to reassess their arrangements.
The underlying frustration is documented. According to Business Group on Health’s 2027 Employer Healthcare Strategy Survey, as reported by Insurance Business Magazine, pharmacy now accounts for 25% of employers’ total healthcare spend — the highest share on record — with drug costs projected to rise 12% in 2026. The combination of rising costs and opaque rebate structures created the conditions for this shift. Transparent PBM models — those that pass rebates directly to the plan and disclose net drug costs — are the market’s response to a system that wasn’t built to show employers what they were actually paying.
What the Movement Doesn’t Cover
The employer demand for pharmacy transparency is real, data-backed, and accelerating. What it doesn’t address is the other channel through which specialty drug spend flows.
Physician-administered specialty drugs — infused biologics, oncology agents, high-cost therapies given in clinical settings — are billed as medical claims, not pharmacy claims. They’re adjudicated through the TPA, governed by the TPA agreement, and subject to manufacturer rebate programs that sit entirely outside the PBM contract. The transparency movement reshaping the pharmacy benefit doesn’t touch this channel. CAA 2026’s rebate pass-through mandate applies to PBMs and pharmacy benefit administration. The medical benefit equivalent doesn’t exist.
There is no transparent TPA movement emerging to parallel what’s happening on the pharmacy side. No structural shift in how employers evaluate TPA contracts for medical benefit rebate accountability. No regulatory provision requiring TPAs to disclose or pass through manufacturer rebates on administered specialty drugs. The accountability framework being built for pharmacy rebates is, by design and by law, a pharmacy benefit framework.
The Data Gap This Creates
PSG’s 2026 Trends in Specialty Drug Benefits Report surveyed employers directly on rebate receipt across both channels. 93% of employers receive specialty drug rebates under the pharmacy benefit. Under the medical benefit, 43% do. The same employers driving the pharmacy transparency shift are, in a majority of cases, operating without a medical benefit rebate process on the other side of their specialty drug spend.
The gap isn’t attributable to a lack of manufacturer rebate programs on medical benefit drugs. Those programs exist for many of the same therapy categories — autoimmune biologics, oncology agents, and other high-cost physician-administered therapies — where pharmacy benefit rebate programs are standard. The gap is structural. The TPA administers the medical claims. The relevant rebate terms live in the TPA agreement. Most TPA relationships haven’t been structured to include a process for pursuing them — and unlike the pharmacy side, no regulatory or market pressure is currently forcing that conversation.
The Planning Implication
Employers heading into 2027 and 2028 renewals are asking sharper questions about their pharmacy benefit arrangements than at any point in the past decade. The transparency movement is producing better contracts, more direct rebate pass-through, and cleaner net cost reporting on the pharmacy side.
The same renewal conversations are, in most cases, not including equivalent questions about medical benefit specialty drug economics. An employer that builds a transparent PBM arrangement covering the pharmacy channel while leaving the medical benefit running without a rebate management process has addressed half the picture.
For advisors and consultants working through those renewal conversations right now: the pharmacy transparency question and the medical benefit rebate question are different conversations, governed by different contracts, handled by different vendors. The first is being driven by regulation and market pressure. The second depends on someone asking.
As employers and their advisors work through 2027 and 2028 PBM renewals, is the medical benefit side of specialty drug economics part of the same conversation — or does it stay in a separate lane? Comment below.
Disclaimer: This newsletter references publicly available findings from Business Group on Health’s 2027 Employer Healthcare Strategy Survey as reported by third-party press coverage, 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 any organization referenced. This newsletter is provided for informational and educational purposes only and does not constitute legal, regulatory, or financial advice. Readers should consult appropriate advisors regarding specific circumstances.