Pharmacy benefits have become one of the largest components of employer health spending, with cancer treatment constituting a major portion—especially as more patients receive expensive specialty and oral therapies. However, responsibility for managing the pharmacy benefit is often divided among human resources, finance, benefits consultants, brokers, insurers, and pharmacy benefit managers (PBMs). A July 2026 statement from SHARx, a procurement management company for high-cost prescription drugs, argues that this fragmented responsibility has created an “accountability gap”: employers may spend heavily on pharmacy benefits without a single person or department being clearly responsible for whether the benefit delivers value. This argument deserves attention, but it is important to separate it from what the available evidence actually establishes.
Federal Evidence has Its Limits. Federal investigations have documented substantial concentration in the PBM market, vertical integration, specialty-drug markups, and the effects of rebate arrangements on drug spending. Oncology literature has also examined PBMs’ roles in formulary placement, utilization management, and patient cost sharing. The evidence does not yet establish that fragmented employer-side responsibility is the primary cause of rising pharmacy costs—or that assigning the benefit to a single executive would, by itself, reduce costs or improve access to cancer treatment.
Key Takeaways
- Employers expect overall health care costs to increase by a median of 9% in 2026. Pharmacy accounted for 24% of employer health care spending in 2024, and employers anticipated pharmacy costs to increase by approximately 11–12% heading into 2026. Cancer remained the leading condition driving employer health care costs.
The FTC reported that the three largest PBMs processed nearly 80% of approximately 6.6 billion prescriptions dispensed in the United States in 2023, while the six largest processed more than 90%. - A second FTC interim report found that the three largest PBMs marked up numerous specialty generic drugs by hundreds or thousands of percent at affiliated pharmacies, generating more than $7.3 billion in dispensing revenue above estimated acquisition costs for 51 specialty generic drugs between 2017 and 2022. These drugs included therapies used to treat cancer and other serious diseases.
- The GAO found that Medicare Part D plan sponsors received $48.6 billion in manufacturer rebates in 2021. For 79 of the 100 drugs receiving the largest rebates, beneficiary payments exceeded plan-sponsor payments after rebates.
- Peer-reviewed oncology literature has documented how PBM policies—including formulary placement, utilization management, specialty tiers, and pharmacy restrictions—can affect oncology practices and patients.
- The available evidence does not establish that a single employer-side owner of the pharmacy benefit would, by itself, reduce pharmacy spending or improve oncology outcomes.
A Concentrated Market, a Fragmented Employer Response
The PBM market has become highly concentrated. In its July 2024 interim staff report, the Federal Trade Commission (FTC) found that the three largest PBMs processed nearly 80% of the approximately 6.6 billion prescriptions dispensed by U.S. pharmacies in 2023. The six largest PBMs processed more than 90%. The FTC also reported that pharmacies affiliated with the three largest PBMs accounted for nearly 70% of specialty-drug revenue. These findings describe a market in which a relatively small number of companies occupy several positions within the prescription-drug supply chain.
This vertical integration gives the largest PBMs significant influence over formularies, pharmacy networks, and specialty drug handling. However, these findings should be read in context: the 2024 report was an interim staff report, and FTC Commissioner Melissa Holyoak issued a formal dissent, arguing that the report did not adequately establish the effect of these practices on consumer prices. That disagreement does not erase the FTC’s underlying market-concentration findings, but it does mean that the report should not be presented as having established every downstream consequence attributed to PBM practices.
The FTC’s second interim report, released in January 2025, focused on specialty generic drugs. It found that the three largest PBMs marked up numerous specialty generics dispensed through their affiliated pharmacies by hundreds or thousands of percent. Across 51 specialty generic drugs examined between 2017 and 2022, affiliated pharmacies generated more than $7.3 billion in dispensing revenue above estimated acquisition costs. These included specialty generics used to treat cancer, HIV, and other serious conditions. While significant for oncology, federal evidence does not establish that employer-side organizational structure drives these market practices.
Where the Accountability Gap Comes From
SHARx argues that pharmacy benefits have become a major employer expense without a clearly identified internal owner. Human resources or benefits teams may negotiate the PBM relationship, finance manages the expenditure, brokers and consultants influence purchasing decisions, and the PBM manages substantial portions of the benefit itself.
According to SHARx, this results in multiple parties managing the benefit, but no single party being clearly accountable for its overall performance. This distinction is useful but remains an industry argument, not a finding established by the FTC, the U.S. Government Accountability Office (GAO), or peer-reviewed research. SHARx also operates in the pharmacy-benefit procurement and management market and has a commercial interest in how employers structure their benefits. Federal evidence provides an independent basis for discussing PBM concentration and specialty-drug pricing, but it does not independently establish SHARx’s conclusion that fragmented employer accountability is the main reason pharmacy spending continues to rise.
Why Oncology Is Particularly Affected
Cancer is not a peripheral issue in the pharmacy-benefit discussion. The Business Group on Health’s 2026 Employer Health Care Strategy Survey found that cancer was the leading condition driving employer health care costs for the fourth consecutive year. Employers also reported that pharmacy represented 24% of health care spending in 2024 and anticipated an 11–12% increase in pharmacy costs heading into 2026. The earlier Business Group survey provides additional context: pharmacy accounted for 21% of employer health care spending in 2021 and 27% in 2023 (from the 2025 survey, not the 2026 survey). For large employers, prescription-drug cost management has become a more active area of benefits strategy. McKinsey reported that about 79% of jumbo employers were using or planning to use methods to manage these costs in 2024, up nearly 50% from 2021.
In oncology, the issue extends beyond drug price. Benefit design determines whether a prescribed therapy requires prior authorization, which specialty pharmacy can dispense it, what cost-sharing applies, and how much a patient must pay before receiving treatment. A 2020 review in JCO Oncology Practice described PBMs’ influence on cancer care through formulary management, utilization management, specialty pharmacies, and other mechanisms. PBMs are particularly important in oncology because prescription drugs play a major role in cancer treatment and more patients receive oral oncology therapies managed through pharmacy benefits. This is an important distinction: the evidence supports a relationship between pharmacy-benefit design and the patient’s experience of obtaining cancer treatment. However, it does not mean every restriction imposed by a PBM is inappropriate, nor does it establish that PBM involvement necessarily increases the clinical cost of cancer care.
Rebates and the Patient’s Cost
Rebates add another layer of complexity. A 2023 Government Accountability Office (GAO) review examined Medicare Part D rebate arrangements using 2021 data. GAO found that plan sponsors received $48.6 billion in rebates from drug manufacturers that year. For 79 of the 100 drugs with the largest rebates, beneficiary payments exceeded plan-sponsor payments after rebates. GAO reported $21 billion in beneficiary payments versus $5.3 billion in plan-sponsor payments for those drugs. The reason: rebates may reduce what a plan sponsor pays for a drug, but beneficiary cost sharing in the Part D structure GAO examined was generally based on the drug’s gross price rather than the post-rebate amount. That does not mean rebates always increase what a patient pays, but it does show that a rebate negotiated between a manufacturer and a plan sponsor does not necessarily translate into a lower point-of-sale cost for the beneficiary.
GAO recommended CMS monitor how rebate arrangements affect formulary design and beneficiary spending. HHS did not concur, citing its existing formulary review process and changes to Medicare Part D from the Inflation Reduction Act. This distinction matters, as the original draft described the recommendation as not implemented; the federal record supports a more precise statement: HHS disagreed with the recommendation.
What This Means for Oral Cancer Therapies
The relationship between benefit design and oncology is not new. In a 2010 analysis published in The Oncologist, Danzon and Taylor examined how insurance coverage and reimbursement affect pricing and access to cancer therapies. They noted that pharmacy-dispensed cancer drugs were increasingly being placed on specialty tiers, where patients could face substantial coinsurance. The paper predates many current oncology therapies and the modern PBM market, so it should not be used as evidence about today’s specific arrangements. Its value is historical: it documents an established policy problem in which benefit design can shift a substantial portion of drug costs to patients. More recent oncology literature reaches a related conclusion: PBM policies can affect what physicians prescribe, how prescriptions are processed, where patients obtain medications, and what patients ultimately pay. For patients receiving oral cancer therapy, administrative and financial decisions can become part of the treatment experience.
What the Data Do Not Establish
The evidence is stronger on some questions than others. The federal record supports several observations:
- The PBM market is highly concentrated.
- The largest PBMs are vertically integrated with other parts of the pharmacy supply chain.
- The FTC has documented substantial markups on a number of specialty generic drugs dispensed through affiliated pharmacies.
- The GAO has documented circumstances in Medicare Part D in which manufacturer rebates reduced plan-sponsor costs without a corresponding reduction in beneficiary payments.
- Oncology literature has documented the effect of pharmacy-benefit policies on cancer practices and patients.
However, the evidence does not establish that the lack of a single employer-side decision maker is the primary cause of rising pharmacy spending. Nor does it establish that consolidating pharmacy-benefit responsibility under one executive would reduce total spending, lower patient out-of-pocket costs, or improve access to cancer treatment. These are reasonable questions for employers to examine, but they are not yet conclusions supported by controlled evidence.
A Governance Problem Without a Tested Solution
This distinction matters because the policy debate can easily shift from documented problems to proposed solutions without evidence that the solution will work. Federal investigations provide substantial evidence about the structure of the PBM market and certain pricing practices. The oncology literature demonstrates that benefit design affects how cancer therapies reach patients. SHARx adds another perspective: employers may not have a clearly defined internal owner responsible for pharmacy benefit performance. That may be a genuine governance problem, but it should remain identified as such rather than presented as an established cause of pharmacy-cost growth.
The more immediate question for employers may be less about assigning blame and more about establishing measurable accountability:
- Who is responsible for the pharmacy benefit?
- What should that person or team be measured against?
- How much does the employer pay after rebates and other concessions?
- What does the patient pay at the point of sale?
- How often are patients required to change pharmacies or obtain prior authorization? In oncology, do benefit-management policies create unnecessary barriers to prescribed therapy?
These are measurable questions. Whether assigning them to a single accountable executive would change the underlying economics of pharmacy benefits remains an open question.
References
[1] Business Group on Health. 2026 Employer Health Care Strategy Survey: Executive Summary, August 19, 2025. Online. Last accessed on August 3, 2026
[2] Federal Trade Commission. Pharmacy Benefit Managers: The Powerful Middlemen Inflating Drug Costs and Squeezing Main Street Pharmacies. Interim Staff Report. July 9, 2024.Online. Last accessed on August
[3] Federal Trade Commission. Holyoak M. Dissenting Statement in In the Matter of the Pharmacy Benefit Managers Report. July 9, 2024. Online. Last accessed on August 3, 2026
[4] Federal Trade Commission. FTC Releases Second Interim Staff Report on Prescription Drug Middlemen. January 2025.(Press Release) Online. Last accessed on August 3, 2026,
[5] U.S. Government Accountability Office. Medicare Part D: CMS Should Monitor Effects of Rebates on Plan Formularies and Beneficiary Spending. GAO-23-105270. September 5, 2023. Online. Last accessed on August 3, 2026
[6] Gupta A, Knott D. Transforming employer health benefits: Large employers’ activist role. McKinsey & Company. June 26, 2025. Online. Last accessed on August 3, 2026.
[7] Royce TJ, Schenkel C, Kirkwood K, Levit L, Levit K, Kircher S. Impact of Pharmacy Benefit Managers on Oncology Practices and Patients. JCO Oncol Pract. 2020 May;16(5):276-284. doi: 10.1200/JOP.19.00606. Epub 2020 Apr 20. PMID: 32310720; PMCID: PMC7351331.
Disclosure
This article is intended for informational purposes for healthcare professionals and does not constitute medical, financial, or legal advice. It discusses health policy and pharmacy benefit management, not a specific drug, clinical trial, or regulatory approval.
Featured image: © 2024 – 2026. Licensed under the Unsplash+ License. Used with permission
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