How Should a Specialty Pharmacy Earn Its Role?

The right specialty pharmacy is not always the one that is owned by the PBM, built into the contract, or easiest to route to. It is the one that can show the best clinical, financial, and member result for that therapy and that population.

3 Min read
September 21, 2026

Crescent Moore, PharmD, PhD

Senior Vice President, Clinical Strategy and Product

Best Practices

Employer benefits leader evaluating specialty pharmacy performance, costs, access, and member outcomes

That standard matters because specialty medications often treat complex or serious conditions. The pharmacy may need access to a limited-distribution drug, experience with the condition, coordination with the prescriber or treatment center, and the ability to resolve difficult coverage issues.

Those capabilities matter.

So does the full cost.

Why employers are looking more closely

Recent financial reporting shows why specialty economics deserve greater attention.

In July, Cigna reported that second quarter adjusted pre-tax operating income from Pharmacy Benefit Services fell 27% from the prior year, while Specialty and Care Services increased 22% to $1.05 billion. ¹

Financial performance does not prove improper routing. It does raise the bar for how employers evaluate whether the selected pharmacy produced the right result.

The Federal Trade Commission added to that attention in a 2025 interim staff report. The report examined 51 specialty generic drugs and found large markups at pharmacies affiliated with the three largest PBMs. ²

The employer question remains:

How do we know the selected pharmacy produced the best result?

Start with the needs of the therapy

Specialty pharmacy selection should begin with the therapy, the member, and the clinical risk, not the ownership model.

Can the pharmacy obtain the drug, understand the condition, coordinate with the prescriber or treatment center, support monitoring and education, and respond when a side effect, coverage change, or delayed shipment puts treatment at risk?

Some therapies have limited distribution, leaving few realistic pharmacy options. Others allow more choice.

Employers should understand whether the channel is clinically required, contractually limited, or simply preferred.

Measure how long therapy takes to begin

A lower price loses value when avoidable delays keep a member from starting treatment. In specialty therapy, time can affect disease control, symptom burden, and whether the member stays engaged long enough to begin therapy.

Employers should examine the time from prescription to first fill, prior authorization turnaround, missing information delays, abandonment, refill gaps, treatment interruptions, and how quickly barriers are resolved once identified.

These measures need context. A complex therapy may require clinical steps that should not be skipped.

The goal is to protect appropriate clinical review while removing delays that add no clinical value.

Compare the final net cost

The amount paid on the claim is only one part of a specialty cost comparison.

Employers need to understand the final net cost after dispensing fees, rebates and other manufacturer payments, pharmacy spread, related-party compensation, member cost share, waste, and clinical-program fees.

A lower claim price may not produce the lowest final net cost. A higher claim price may be defensible if the services attached to it reduce waste, prevent avoidable delays, or improve continuity of therapy.

The standard should be simple: show the cost, show what changed, and show whether the result was better.

Understand how the channel affects treatment decisions

The pharmacy channel can influence more than where the prescription is filled. It can affect which product is used, how quickly a therapy changes, whether a biosimilar is considered, and whether a medical-benefit therapy moves to a lower-cost site of care.

Employers should be able to ask direct questions. Was a clinically appropriate lower-cost biosimilar available? Was it considered promptly? Did any financial incentive favor a higher-cost product? Could the same appropriate treatment be delivered safely at a lower-cost site?

Employers do not need to practice medicine. They do need to know whether the recommended path was clinically appropriate, economically rational, and aligned with the member’s best outcome.

Measure the member’s result

Specialty treatment can require a member or caregiver to coordinate with the prescriber, pharmacy, health plan, PBM, manufacturer, and treatment center.

The selected pharmacy should reduce friction, not create another handoff for the member to manage.

Did the member understand the next step and expected cost? Did the medication arrive on time? Was there one clear place to get help? Were affordability, access, refill, or transition issues resolved before therapy was disrupted?

Call volume and outreach show activity.

The result is simple: the member received the right therapy, understood what to do next, and avoided unnecessary delay, confusion, or interruption.

Affiliation is not the standard

An affiliated specialty pharmacy may provide strong clinical support, favorable economics, and useful coordination. An independent or health-system pharmacy may be the better choice for another therapy or population.

Ownership alone does not answer the employer’s question. Evidence does.

Employers should be able to see why the channel was selected, how it performed, and whether another option could have produced a better result.

Specialty pharmacy should be earned, not assumed. The standard should be simple: protect access, show the full cost, and hold every channel accountable for the outcome.

How Should a Specialty Pharmacy Earn Its Role?

3 Min read

Crescent Moore, PharmD, PhD

Why employers are looking more closely

Start with the needs of the therapy

Measure how long therapy takes to begin

Compare the final net cost

Understand how the channel affects treatment decisions

Measure the member’s result

Affiliation is not the standard

Tags

Recommended Reads

Share

Company

Resources

Connect

Follow us

Download the PBM Reform Readiness Checklist

Download the GLP-1 Planning Checklist