Behind the “Black Box;” As 2026 Rx Price Hikes Emerge, SHARx Exposes Specialty Drug Pricing

Headlines about prescription drug sticker-shock miss the real problem: Specialty pharmacy rules, PBM incentives, and opaque contracting are determining access and out-of-pocket costs in a system that most U.S. consumers don’t understand. Will 2026 be the year that a push for transparency will finally address specialty drug approvals, delays, and patient bills? 

ST. LOUIS, Feb. 9, 2026 /PRNewswire/ — As New Year prescription drug prices reset, the public is starting to see how pharmaceutical companies will raise U.S. prices on at least 350 branded medications in 2026, according to reporting in Reuters. This median increase of about 4% is keeping list prices in the spotlight, but one industry expert says the biggest affordability and access shocks often happen in a less visible place: the specialty drug market’s “black box,” where contracting terms, pharmacy requirements, and utilization controls can determine whether a patient receives lifesaving therapy 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 of 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.” 

Pricing is Hard to See and Even Harder to Audit 

Specialty drugs have transformed treatment for complex conditions, but access and affordability are increasingly shaped by nontransparent rules that most patients, providers, and many employers cannot easily evaluate. SHARx points to three compounding realities:

• “Specialty” labeling is a PBM control lever. This system lets the PBM direct fulfillment to its own specialty pharmacy and lock in big rebates. Those rebates often run through PBM-owned GPOs, where additional, undisclosed amounts can be skimmed off.
• Too much gatekeeping stands between patients and care, turning coverage rules like prior authorization and limited pharmacy networks into delays, denials, and surprise costs.
• Middleman’s market structure amplifies opacity. The Federal Trade Commission (FTC) has noted that PBMs sit at the center of a complex distribution chain. And, after decades of consolidation, the three largest PBMs manage nearly 80% of prescriptions filled in the U.S.

“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.” 

The Long and Winding Path to a “Black Box”

SHARx notes that PBMs originated as a member-convenience tool which then evolved into a far more complex and profitable control point over access and pricing.

“PBMs started in the ’80s… as point-of-sale adjudication to simplify the member journey,” Pruitt said. “What started as a great idea for member convenience has morphed into this juggernaut of vertical integration.” 

SHARx argues that when PBM contracts, network rules, and specialty pharmacy requirements are not transparent or auditable, plan sponsors can struggle to understand the true drivers of specialty cost, and patients can face delays and surprise cost-sharing.

Federal Scrutiny Underscores Concerns 

Federal scrutiny has increasingly focused on specialty drug business practices. In January 2025, the FTC released an interim staff report finding PBMs can exert significant influence over specialty generic drugs, including significant markups and practices that can steer prescriptions toward PBM-affiliated pharmacies. 

SHARx says these findings align with what many plan sponsors and providers experience on the ground: specialty pricing and access decisions can be embedded in contracting and dispensing rules that are difficult to evaluate externally.

The challenge is especially acute for patients who rely on specialty therapies for cancer, rare/genetic diseases, transplants, and other serious conditions, with limited or no alternatives—where administrative delays and inconsistent cost-sharing can carry high clinical stakes.

“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. Even with years of experience, my wife and I still spend hours over several weeks just to get one prescription filled,” Pruitt said.

A Call to Action 

As 2026 price increases begin, SHARx is calling for greater transparency and accountability in specialty drug pricing and access practices, including:

• Clearer disclosure of what drives patient cost-sharing for specialty medications.
• Greater visibility into PBM-affiliated specialty pharmacy steering and network requirements.
• Contracting and reimbursement transparency that enables plan sponsors to understand net costs, incentives, 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. It’s like making people get approval from their home insurer before the fire department can turn on the hose.“ Pruitt said “And until we fix it, patients will keep paying the price in delays, denials, and preventable harm.”

About SHARx 

SHARx was founded to fight back against the broken system of overpriced prescription drugs. Industry pioneers Corey Durbin and Paul Pruitt built SHARx to put people before profits. With an innovative and ethical sourcing model, SHARx cuts through the waste with radical transparency, common-sense cost containment, and a member-first approach. No hidden markups. No games. Just the meds people need, delivered affordably, reliably, and with dignity. 

Learn more at: https://sharxplan.com 

References: 

• Erman, M. (2026, January 2). Exclusive: Drugmakers raise US prices on 350 medicines despite pressure from Trump. Reuters. reuters.com/business/healthcare-pharmaceuticals/drugmakers-raise-us-prices-350-medicines-despite-pressure-trump-2025-12-31/
• Federal Trade Commission. (2024, July 9). FTC releases interim staff report on prescription drug middlemen. ftc.gov/news-events/news/press-releases/2024/07/ftc-releases-interim-staff-report-prescription-drug-middlemen
• Wadsten, L., & Horwitz, N. (2026, January 6). “B*******” — The new way health giants hide billions. Hunterbrook Media. https://hntrbrk.com/pbmgpo/
• Federal Trade Commission. (2025, January 14). FTC releases second interim staff report on prescription drug middlemen. ftc.gov/news-events/news/press-releases/2025/01/ftc-releases-second-interim-staff-report-prescription-drug-middlemen
• Gibson, K. (2024, July 9). FTC says prescription middlemen are squeezing Main Street pharmacies. CBS News. cbsnews.com/news/ftc-pbm-investigation/

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