Have you checked what one member on a specialty drug now costs your fund over the course of a plan year? The average cost of specialty drugs in 2026 can range from $60,000 to $250,000 a year for one brand therapy-with gene therapies costing more.
For a health fund, a single high-cost claim can put unexpected pressure on an entire plan year’s budget. Most funds do not see this coming until the claim arrives. One diagnosis can move a fund from a healthy reserve to a shortfall within a few months. And this happens while the cost of basic coverage keeps climbing for everyone.
KFF reported that the average family premium hit $26,993 in 2025, with workers contributing an average of $6,850 toward their coverage.
For fund administrators, rising premiums are only part of the challenge. This is where pharmacy assistance programs can become an important part of the strategy. Our sponsor, Payer Matrix, helps connect eligible members with available assistance for high-cost medications.
Specialty drugs treat chronic, rare, and complex conditions. They can need special handling or close monitoring. Because of that, one specialty drug cost can quickly affect a self-funded health plan’s budget.
The following examples illustrate just how significant those costs can be:
When reviewing 2026 specialty drug cost data, it is important to look beyond last year’s pharmacy budget. A formulary can help manage how specialty drugs are covered and used, but it cannot eliminate the underlying cost of high-priced therapies.
Brand-name drug list prices can increase by nearly 10% annually, adding to the pressure on pharmacy budgets. Payer Matrix reports that 45% of drug spend comes from just 5% of members, while half of all drug spending now comes from specialty medications. Projections indicate that specialty spending could exceed 60% in 2026, meaning a relatively small group of claims can have a significant effect on a health and welfare fund.
A fully insured group spreads a $600,000 claim across a carrier's broader book of business. A self-funded plan, however, pays claims from funds set aside for its own members. This includes self-funded employers and union benefit plans. That is why health plan cost savings for self-funded employers often start at the pharmacy line.
The financial impact of high-cost claims can show up in several ways:
The attachment point matters here because it sets the level at which the policy may begin to reimburse eligible claims. However, the policy terms, exclusions, and timing rules determine what counts. An assistance program may reduce the cost of a medication, but that does not necessarily mean the claim leaves the fund’s overall risk profile.
Manufacturer patient assistance programs can provide certain brand specialty drugs at no charge to eligible patients. However, many members may not know these programs exist, while others may feel overwhelmed by the application process and paperwork. That is where assistance program navigation can help, making it easier for eligible members to identify and access available support.
Payer Matrix connects members with available programs for more than 300 medications. Its care coordinators review eligibility, gathering requested documents, completing forms, tracking deadlines, and helping schedule refills. Members do not pay for this support; instead, the plan sponsor pays an advocacy fee. Payer Matrix also states that its program holds URAC accreditation for care management standards.
Each manufacturer has its own eligibility requirements, including income, diagnosis, medical need, and age. If a member does not qualify, the plan can review whether an exception is possible, while the member’s doctor can consider an equivalent alternative. Eligibility, approval, and medication supply timelines can vary depending on the drug and manufacturer.
Picture two members receiving hemophilia therapy at $600,000 each per year. Together, those two claims cost the plan $1.2 million a year. If both members qualify for manufacturer assistance programs, the plan may pay an advocacy fee instead of the full drug cost. The potential savings could be substantial, potentially approaching $1 million in this example, depending on eligibility, program rules, and plan agreements.
|
Plan element |
Standard coverage |
Assistance program navigation |
|
Plan cost |
Full drug price, less rebates |
Advocacy fee for an eligible member |
|
Paperwork |
Member and doctor |
Dedicated care coordinator |
|
Stop-loss exposure |
May count toward the attachment point |
Impact should be confirmed against the policy terms |
Trustees should come to the next meeting with clear numbers - not just broad concerns about pharmacy spending. Start with these five areas:
These are the kinds of issues fund administrators regularly evaluate, and the Association of Benefit Administrators provides a forum for benefit professionals to share strategies and solutions for managing health and welfare plan costs.
Specialty drug prices may continue to rise through 2026. Your fund cannot control the list price, but it can take steps to manage how much the plan ultimately pays. Members deserve access to the medications their doctor prescribed, while trustees need a balance sheet that can last through the year. Careful claims review, thoughtful plan design, and well-run assistance programs can help protect both.
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Ready to review your fund's specialty spend? Contact the ULA Network, and we will point you to the right resource.
Most brand specialty drugs can cost $5,000 to $20,000 per month, with some therapies reaching $60,000 to $240,000 or more per year. Certain gene therapies can cost substantially more. Actual costs vary by drug, condition, dosage, and treatment plan.
Self-funded plans are not required to cover every named brand specialty drug under the ACA coverage mandate rules. However, a self-funded health plan must still follow applicable federal requirements. Those rules include benefit limits, cost sharing, and plan documents. Trustees should check the wording with fund counsel before excluding a product.
According to Payer Matrix, members do not pay for its assistance program navigation services; the plan sponsor pays the advocacy fee. Eligible members may be able to continue their prescribed therapy while receiving support from a care coordinator. Final costs and coverage depend on the plan’s terms and the applicable manufacturer assistance program.
Enrollment timelines vary by program and depend on how quickly complete documentation is submitted and reviewed. Care coordinators can help members complete and submit required paperwork and may help arrange bridge supplies when available and permitted by the manufacturer program.
The member can still complete the eligibility review to determine whether another assistance option is available. If the member does not qualify for a manufacturer program, the plan can review other coverage options, including whether an exception is appropriate. The member’s doctor may also consider an alternative therapy that is covered under the plan.