68
2026
SPECIALTY PHARMACY
Outlook
SPRING 2026 I RETAIL/COMMUNITY • SPECIALTY • LTC
Ensuring patients have access to the medications they need from
the specialty pharmacy of their choosing and championing
protections essential to the long-term sustainability of the
specialty pharmacy business model have always been top
priorities for NASP.
The Inflation Reduction Act’s (IRA) drug negotiation
provisions, the new Medicare Transaction Facilitator (MTF)
infrastructure, “maximum fair price” (MFP) constructs, MFN-
style reference pricing, and the introduction of TrumpRx and
other direct-to-consumer (DTC) channels together represent
a major structural realignment for specialty pharmacy. These
policies promise lower patient and payer costs, but they also
compress traditional buy-and-bill reimbursement processes
and dispensing margins and risk undermining specialty
pharmacy financial viability and the very personalized, high-
touch specialty pharmacy services that patients rely on.
IRA Pricing & MFPs: Margin Compression
and Operational Burden
Under the IRA’s Medicare Drug Price Negotiation Program, CMS now
negotiates “maximum fair prices” for selected high-spend Part D and
Part B drugs, with the first group of MFPs taking effect in January 2026
and expanding in subsequent years.1,2 Early analyses from CBO and
MedPAC indicate that negotiated price ceilings will exert downward
pressure on both list and net prices across therapeutic classes.3,4
For specialty pharmacies, this changes both the revenue model
and the cash-flow profile. MFPs are, by design, substantially below
current net prices which will likely compress gross margins unless
acquisition costs fall in lockstep. This margin is the economic
foundation supporting specialty pharmacist clinical services
and specialty patient management and care coordination. At
the same time, the MTF will sit in the middle of claims flows to
exchange pharmacy claims data with manufacturers and route
retrospective MFP refund payments back to dispensing entities.5,6