The Top 3 Comp Pharmacy Trends That Will Actually Matter in 2026
P4P #1 — Resetting the Board for 2026
Every year starts with predictions. Most of them are polite. Most of them are safe. Most of them age poorly.
This isn’t that.
This is Prescription for Performance #1 for 2026—written for leaders who actually have to make decisions, explain them, and live with the downstream consequences.
If 2024 and 2025 were about awareness, 2026 is about enforcement—by regulators, by cities, and increasingly by buyers themselves.
Here are the three trends that will define comp pharmacy this year, whether the industry is ready or not.
1. Transparency Is No Longer Optional—and It Can’t Be Retrofitted
Let’s start with the obvious one—because it’s no longer theoretical. Transparency is now being demanded, enforced, and litigated.
Federal lawsuits against the largest PBMs have pulled back the curtain on unfair pricing, rebate games, and conflicted incentives. At the same time, cities and public entities are passing their own transparency and audit requirements, forcing PBMs to explain—not just report—how money actually moves.
Here’s the part the industry doesn’t like to say out loud:
You can’t bolt transparency onto a business model that depends on opacity.
The largest PBMs were not designed for clarity.
They were designed for scale, leverage, and complexity.
And complexity is a terrible place to hide when:
Regulators are asking second and third questions
Cities want audit rights written into contracts
Public buyers have to defend decisions in open meetings
This is why transparency initiatives from legacy incumbents often feel performative:
More dashboards
More reports
More “trust us” language
But very little structural change.
PBMs built differently—like Prodigy—don’t have to retrofit transparency. It’s native to the model. When incentives are aligned and economics are straightforward, transparency isn’t a risk—it’s a strength.
2026 reality: Transparency is no longer a differentiator. It’s a gate. And some PBMs simply won’t fit through it.
2. Specialty Drugs Are the Fastest-Growing Force in Workers’ Comp—and Discounts Won’t Save You.
Specialty drugs are no longer “emerging” in workers’ comp. They’re here—and accelerating.
Driven by:
A robust FDA specialty pipeline
Expanded presumptive coverage laws
Increased use of biologics, injectables, and infused therapies
Specialty is now the fastest-growing segment of comp pharmacy spend. And yet, many strategies still revolve around one tired idea: “Can we get a better discount?”
That mindset misses the point.
In workers’ comp, specialty cost isn’t driven primarily by unit price. It’s driven by:
Clinical appropriateness
Timing of care
Site of care
Duration of care
Whether the therapy actually matches the condition
We’ve already covered this in prior P4P articles—certain specialty drugs and conditions consistently drive outsized claim impact. The lesson hasn’t changed, but the stakes have.
The winning strategy in 2026 goes beyond discounts and asks:
Moving from transaction review to clinical pathway design
Shifting focus from “Is this allowed?” to “Is this appropriate now?”
Treating specialty as a care strategy, not a billing anomaly
This is where models like Specialty Nexus matter—not just as a carve-out, but as an operating layer that brings clinical governance to specialty spend.
2026 reality: If your specialty strategy stops at pricing, you don’t have a strategy—you have exposure.
3. The PBM Model Itself Is Under Scrutiny—and Fiduciary Discipline Is the New Standard.
At this point, every PBM should have gotten the memo. This is the hardest conversation—and the most important.
The traditional PBM model is being questioned not because it’s unpopular, but because it’s indefensible under scrutiny.
For years, the industry normalized practices that would never survive a fiduciary lens:
Wonky pricing hidden behind “network guarantees”
Rebates disconnected from clinical decisions
Formularies influenced by economics no one wants to explain
As prior P4P articles have called out: these aren’t edge cases. They’re structural features of legacy PBM design.
In 2026, that matters—because buyers are changing how they evaluate partners. The new questions sound like:
Who is this PBM actually working for?
Where do incentives sit?
Can this model withstand an audit, a regulator, or a public hearing?
PBMs like Prodigy that operate with fiduciary discipline, clean economics, and explicit controls don’t fear these questions. They welcome them. Others will spend the year managing narratives instead of outcomes.
2026 reality: The PBM model is no longer judged by promised savings—but by whether it can survive daylight.
The Throughline for 2026
These aren’t three separate trends. They’re one story.
Transparency pressures expose weak models.
Specialty growth amplifies clinical risk.
And legacy PBM economics struggle to justify under scrutiny.
2026 will reward leaders who:
Choose partners built for scrutiny, not scale alone
Treat specialty as a clinical challenge, not a pricing exercise
Demand fiduciary clarity instead of accepting industry norms
The comp pharmacy system isn’t collapsing. It’s being forced to grow up.
And as always, performance follows design.
Transparency isn’t coming—it’s here. Specialty isn’t slowing. And PBM models are being tested in public. In 2026, leaders will design outcomes. Everyone else will explain them. Let’s schedule time to plan your 2026.
—Del
About P4P
A Strategic Dose of Clarity in a Noisy PBM Market
Written by Prodigy CEO, Del Doherty, P4P delivers sharp, consultative insights for decision-makers who are tired of legacy models, hidden costs, and passive vendors. Each piece is a prescription—cutting through the noise to reveal what actually drives performance in pharmacy benefit management. No fluff. No spin. Just insight that pays off.
