Gross-to-Net in 2026: Why Pharma CFOs Can’t Afford to Wait

For decades, Gross-to-Net (GTN) has been one of the more complex areas of pharmaceutical finance. It sits at the intersection of pricing, market access, contracting, and revenue accounting, translating list prices into the net revenue a company ultimately recognizes. Historically, GTN complexity was tolerated because it was largely predictable, manageable with experienced teams, and corrected through periodic true-ups. That reality no longer holds.

As the industry moves into 2026, GTN is becoming one of the most significant sources of revenue volatility and financial risk for pharmaceutical companies. Regulatory reform, payer behavior, and channel dynamics are changing simultaneously, and many GTN models were never designed to absorb this level of uncertainty. For CFOs, this is no longer a question of operational efficiency—it is a matter of forecast credibility, audit defensibility, and earnings confidence.

A regulatory environment that redefines GTN

The Inflation Reduction Act (IRA) has fundamentally altered the financial mechanics of GTN. Medicare inflation rebates introduce entirely new liability categories that must be forecasted, accrued, and settled with precision. These rebates are not theoretical; invoicing begins in 2025, meaning finance teams must operationalize these calculations now, not later.

At the same time, government-negotiated drug pricing will take effect for select products starting in 2026. This directly impacts net price assumptions and long-term revenue projections. CFOs must now consider not only current pricing strategies but how future negotiated prices cascade through GTN models over multiple years.

Medicaid programs add another layer of complexity. Pilot programs, potential rebate reforms, and evolving state-level policies increase both financial exposure and modeling uncertainty. Some programs are optional, others mandatory, and many involve timing and calculation nuances that materially affect accrual accuracy. Layered on top are state drug pricing transparency laws and heightened enforcement activity, increasing scrutiny of assumptions and methodologies used to calculate GTN.

Individually, each of these changes is manageable. Collectively, they redefine what “good” GTN management looks like.

Why traditional GTN approaches are no longer sufficient

Most GTN processes were built for a more stable environment. They rely heavily on spreadsheets, manual reconciliations, and periodic adjustments informed by historical patterns. That approach struggles when:

• New liability types emerge with limited precedent
• Channel mix shifts faster than planning cycles
• Policy interpretations evolve mid-year
• Finance must explain variance drivers earlier and more frequently

In this environment, GTN discrepancies are no longer insignificant or easily absorbed. A modest misestimate in rebate exposure or channel utilization can create material earnings swings, often discovered late in the close cycle. This puts finance leaders in a reactive position: explaining results instead of managing outcomes.

The result is growing tension between Finance, Market Access, and Commercial teams. Pricing decisions are made without full visibility into downstream GTN impact. Market access agreements perform differently than forecasted. Finance is left reconciling assumptions after the fact, under pressure from auditors, executives, and investors.

GTN as a strategic finance capability

What is changing most dramatically is how GTN is perceived at the executive level. GTN is no longer viewed as a technical accounting exercise; it is increasingly recognized as a strategic capability that influences pricing strategy, launch planning, and capital allocation decisions.

Boards and investors expect fewer surprises. They want confidence that revenue forecasts incorporate regulatory risk, payer behavior, and realistic assumptions about net price realization. Auditors expect traceability, consistency, and defensibility. Internally, CFOs are being asked not just what the net number is, but what could cause it to move—and how quickly leadership would know.

Meeting those expectations requires a different GTN operating model. One that emphasizes scenario planning over static forecasts, predictive insight over historical reconciliation, and governance over heroics.

What Leading CFOs Are Doing Differently

Forward-looking finance leaders are strengthening GTN in several key ways:

• Scenario-driven planning: Modeling regulatory, pricing, and access scenarios before they impact earnings
• Earlier variance detection: Identifying GTN risk drivers weeks earlier in the quarter, not days after close
• Tighter cross-functional alignment: Ensuring pricing, market access, and finance operate from consistent assumptions
• Improved audit readiness: Maintaining clear lineage, documentation, and controls across GTN calculations
• Predictive insight: Moving from “what happened” to “what is likely to happen next”

This is not about adding complexity for its own sake. It is about restoring predictability and control in an environment where external forces increasingly dictate net revenue outcomes.

The cost of waiting

For CFOs, the cost of delaying GTN modernization is rising. Regulatory pressure is not slowing down. Data volumes are increasing. Expectations for forecast accuracy and transparency are higher than ever. Teams relying on legacy processes are spending more time explaining past results and less time shaping future outcomes. By contrast, organizations that invest now in strengthening GTN governance, modeling discipline, and predictive capability position themselves to navigate uncertainty with confidence. They reduce earnings volatility, shorten close cycles, and improve credibility with stakeholders who matter most.

GTN in 2026 is not simply harder: it is fundamentally different. It sits at the center of regulatory reform, pricing pressure, and financial accountability. CFOs who treat GTN as a strategic finance function rather than a downstream adjustment will be better equipped to protect earnings, defend forecasts, and guide their organizations through a rapidly evolving landscape.

Waiting is no longer a choice. In today’s environment, it is a risk.

Ready to transform your GTN capabilities? Contact us to get started.

 

If you’d like to read more, we recommend:

• How Argano helps pharma finance leaders transform revenue complexity into your strategic advantage. 
• 5 Essential Characteristics of Leading Gross to Net Forecasting Organizations