ST. LOUIS — As prescription drug prices reset for the new year, attention once again shifts to list price increases across hundreds of branded medications. However, specialty pharmacy practices, rather than headline price hikes, are often the key factors influencing patient access and out-of-pocket costs, according to SHARx.
Reporting cited by Reuters shows pharmaceutical manufacturers raising U.S. prices on at least 350 branded drugs in 2026, with a median increase of about 4 percent. While those increases fuel consumer concern over sticker shock, SHARx argues that the most significant affordability and access disruptions occur within what it describes as the specialty drug market’s “black box,” where contracting terms, pharmacy requirements, and utilization controls determine whether patients receive treatment on time and what they ultimately pay.
“Price announcements get headlines, but specialty drug affordability is often determined behind the scenes,” said Paul Pruitt, chief growth officer at SHARx. “In the specialty channel, contracting terms, pharmacy requirements and utilization controls can decide whether a patient starts therapy on time and what they’re charged without clear visibility into how those decisions were made.”
Specialty drugs and opaque rules
Specialty medications have transformed care for cancer, rare diseases, and complex chronic conditions. However, SHARx states that access is increasingly influenced by non-transparent rules that many patients, providers, and employers find difficult to assess. The company highlights three factors it says worsen the issue:
- Specialty classification as a control lever. Labeling a drug as “specialty” can enable pharmacy benefit managers to mandate fulfillment through PBM-owned specialty pharmacies, collecting rebates and fees that might not be fully disclosed.
- Administrative gatekeeping. Prior authorization requirements and limited pharmacy networks can lead to delays, denials, and unexpected patient costs.
- Consolidation among intermediaries. After decades of mergers, the three largest PBMs control nearly 80 percent of prescriptions in the U.S., centralizing decision-making power within a complex distribution network.
“In specialty drugs, pricing opacity isn’t just a financial issue; it can become a clinical issue,” Pruitt said. “Even if you have insurance, it doesn’t mean you can afford the drug or that you won’t be required to jump through a bunch of hoops to get what you need.”
Federal scrutiny adds pressure
Concerns about specialty drug pricing practices have gained more federal attention. In January 2025, the Federal Trade Commission issued an interim staff report revealing that PBMs can significantly influence specialty generic drugs, including through markups and practices that direct prescriptions to PBM-affiliated pharmacies.
SHARx states that these findings reflect what many plan sponsors and providers experience daily: specialty pricing and access decisions embedded in contracts and dispensing rules that are challenging to audit externally. The stakes are particularly high for patients with cancer, rare or genetic diseases, and transplant needs, where treatment delays or inconsistent cost sharing can have serious clinical consequences.
“As a parent of two kids who depend on specialty meds, I’ve watched prior-authorization red tape and specialty pharmacy hurdles turn routine refills into all-out battles,” Pruitt said. “Even with years of experience, my wife and I still spend hours over several weeks just to get one prescription filled.”
Push for transparency in 2026
As 2026 price increases take effect, SHARx calls for increased transparency and accountability throughout the specialty drug channel. The company advocates for clearer disclosure of how patient cost sharing is calculated, more visibility into PBM-affiliated specialty pharmacy steering, and transparent contracting that enables plan sponsors to understand true net costs and patient outcomes.
“Healthcare coverage is a great thing in theory; in reality, it’s often used as a barrier to delay patients’ access to medicine,” Pruitt said. “It’s like making people get approval from their home insurer before the fire department can turn on the hose. And until we fix it, patients will keep paying the price in delays, denials and preventable harm.”
Founded by industry veterans Corey Durbin and Paul Pruitt, SHARx is a prescription benefit company focused on transparent pricing and member-first sourcing. The company states its goal is to reduce hidden markups and complexity in prescription drug access while enhancing affordability and reliability for patients.
Learn more at: https://sharxplan.com
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