pharmacy benefit manager · pbm market share
The Big 3 PBMs: An Analysis of Market Share & Dominance
November 9, 2025
Updated August 25, 2026
50 min read
Explore the top 3 PBMs controlling 80% of the U.S. market. Updated with 2026 federal reform law, FTC Express Scripts settlement, DOJ UnitedHealth probe, and landmark rebate pass-through requirements.
- 01Express Scripts, CVS Caremark, and OptumRx together process roughly four out of every five U.S. prescription claims.
- 02Decades of mergers and vertical integration placed the leading PBMs inside insurer and pharmacy conglomerates.
- 03Rebates, administrative fees, and spread pricing are central to PBM revenue models and transparency concerns.
- 04Federal reform, FTC actions, and state measures are reshaping rules for specified PBM arrangements.
- 05Large PBM decisions affect drug pricing, pharmacy reimbursement, patient access, and employer benefit design.
Executive Summary
Pharmacy Benefit Managers (PBMs) have evolved into extremely powerful intermediaries in the U.S. drug supply chain. In the current market, three PBM firms control the vast majority of prescription benefits. According to recent industry analyses, Cigna’s Express Scripts, CVS Health’s CVS Caremark, and UnitedHealth’s OptumRx together process roughly 80% of all U.S. pharmacy claims in 2024 ([1]) ([2]). This concentration is unprecedented: a JAMA analysis of 2023 data reports that the top three PBMs (CVS Caremark, Express Scripts, OptumRx) accounted for about 74–79% of retail prescriptions ([3]) ([4]). Measured by the Herfindahl–Hirschman Index (HHI), the retail PBM market has an HHI of ~1972, a measure consistent with a highly concentrated market; HHI alone does not establish monopoly status ([4]). This extreme market concentration has major implications. In a landmark shift, Congress passed comprehensive PBM reform as part of the Consolidated Appropriations Act, 2026 (signed February 3, 2026), requiring 100% rebate pass-through, banning spread pricing in Medicare Part D, and mandating any-willing-pharmacy provisions starting in 2028–2029. Meanwhile, the FTC secured a landmark settlement with Express Scripts in February 2026, requiring fundamental changes to its PBM business model expected to lower patient costs by up to $7 billion over 10 years.
This report provides a detailed examination of the “Big Three” PBMs – Express Scripts (owned by Cigna/Evernorth), CVS Caremark (CVS Health), and OptumRx (UnitedHealth Group) – including their history, business models, market positions, and controversies. We analyze market data showing their dominance ([1]) ([2]), and explore how their vertical integration with large insurers has shaped the PBM industry. The Big Three have grown through major mergers and exclusive contracts (e.g. CVS’s acquisition of Caremark in 2007 ([5]), Cigna’s acquisition of Express Scripts in 2018 ([6]), and UnitedHealth’s launch and expansion of OptumRx ([7])), strategically absorbing competitors and insurer clients. For example, in 2024 Express Scripts won a new five-year contract to serve 20 million Centene members previously with CVS ([8]), immediately catapulting Express Scripts to the top of the market share (up to ~30% of claims) and causing CVS Caremark to lose market volume ([1]) ([8]). Table 1 (below) summarizes recent market-share data.
The Big Three PBMs have been the subject of congressional and regulatory reviews focused on market structure, pricing, and transparency. For instance, a 2024 U.S. House Oversight report examined spread pricing, formulary rebates, and vertical integration among the largest PBMs ([9]). Similarly, a January 2025 FTC staff report analyzed dispensing revenue for selected specialty generic drugs at pharmacies affiliated with Caremark, Express Scripts, and OptumRx, reporting more than $7.3 billion above the National Average Drug Acquisition Cost from 2017–2022 ([10]). These reports have informed policy discussions about PBM rebate incentives, formulary placement, and pricing transparency ([9]) ([10]).
PBM practices have serious real-world effects. Many independent and rural pharmacies report unsustainable reimbursement rates, contributing to waves of pharmacy closures ([9]) ([11]). Patients and payers may still face high drug costs and out-of-pocket spending, while PBM contracts determine how negotiated savings are allocated. The opaque nature of PBM contracts (such as allowing spread pricing – charging insurers more than pharmacies receive) and rebate retention has drawn bipartisan calls for reform ([9]) ([12]). Various legislative measures (state and federal) now aim to enhance transparency and restrict profit-taking by PBMs: proposed federal bills (e.g. in 2024–2025) would ban spread pricing and require 100% rebate pass-throughs for Medicare and Medicaid contracts ([13]) ([14]). A Missouri court recently allowed an FTC antitrust case to proceed against the Big Three PBMs, unblocked by the PBMs’ challenge ([15]) ([16]). These actions reflect growing consensus that PBM practices may need intervention.
This report will: provide historical context on PBMs and the rise of vertical integration ([17]) ([18]); profile each of the Big Three (including their corporate evolution and current scale); present detailed market analyses (market share, concentration indices, drug trends) with data tables; examine their business models (rebates, fees, spread pricing) and controversies (legal cases, legislative hearings); and discuss implications for drug prices, pharmacies, patients, and policy. We draw extensively on industry reports, academic studies, regulatory filings, and news coverage to give a comprehensive, evidence-based picture of how these three PBMs dominate the market and what that means for the healthcare system.
Share of total U.S. prescription claims market held by the three largest PBMs in 2024
Herfindahl Hirschman Index for the overall PBM market across all payers
Dispensing revenue above the National Average Drug Acquisition Cost reported by FTC staff
Centene members covered by the Express Scripts contract won in January 2024
Introduction and Background
A Pharmacy Benefit Manager (PBM) is a third-party administrator of prescription drug programs. PBMs act as intermediaries between health plan sponsors (insurers, employers, governments), pharmacies, pharmaceutical manufacturers, and drug wholesalers ([19]). Their core functions include designing drug formularies (determining which drugs are covered and at what tier), negotiating drug prices and rebates with manufacturers, adjudicating and paying pharmacy claims, and managing pharmacy networks (which pharmacies participate) ([20]) ([3]). In exchange for these services, PBMs charge health plans administrative fees and often retain a portion of the manufacturer rebates on drugs. They may also obtain revenue from spread pricing – charging plan sponsors more than what is paid to pharmacies – and other opaque revenue streams.
Originally, PBMs began as simple claims processors in the 1960s. Over decades, however, they acquired more sophisticated roles. As Mattingly et al. (2024) note, PBMs “evolved in parallel with the pharmaceutical manufacturing and health insurance industries” through horizontal and vertical integration ([21]). They now wield significant influence over every step of drug distribution. This rise has coincided with concerns: critics point to “lack of competition, pricing (opacity), agency problems, and lack of transparency” in PBM operations ([22]).
Numerous industry reports confirm that the PBM market is currently highly concentrated among very few firms. For 2023 and 2024 data, analysts find that the three familiar PBM names – CVS Caremark (CVS Health), Express Scripts (Cigna/Evernorth), and OptumRx (UnitedHealth) – dominate U.S. prescription claims. For example, the Drug Channels Institute reports that “nearly 80% of all equivalent prescription claims were processed by three familiar companies” (CVS Caremark, Express Scripts, OptumRx) in 2024 ([23]). Becker’s Hospital Review similarly notes that in 2024 Express Scripts handled 30% of all claims (driven by a new Centene contract), CVS Caremark 27%, and OptumRx 23%; together these three processed about 80% of U.S. prescription claims ([1]). (See Table 1, below.) An AMA analysis of 2022 data likewise found the top four PBMs account for ~70% of the market, with CVS (21.3%), OptumRx (20.8%), Express Scripts (17.1%), and Prime Therapeutics (10.3%) being the largest ([24]).
These figures underscore that PBM power is tightly concentrated. A recent JAMA study of 14 billion U.S. retail pharmacy fills in 2023 confirmed this: the overall PBM market exhibited a Herfindahl–Hirschman Index (HHI) of about 1972 – a value indicating high concentration. In aggregate, the Big Three accounted for 73.6% of prescriptions across all payers ([4]). Concentration varied by segment – e.g. CVS dominated Medicaid managed care (39.2% share), while market shares also differed across Medicare Part D and commercial coverage ([2]) – but no market was immune. Even in commercial insurance, the top PBMs held nearly three-quarters of claims volume ([2]).
This report examines how these three PBMs achieved such dominance and what it means. We begin with a historical perspective on the PBM industry’s evolution and consolidation. We then provide in-depth profiles of each of the Big Three, including their corporate history and recent developments. Next, we analyze up-to-date market data on PBM share and concentration (including charts and tables). We explore PBM business models – how revenues and profits are generated – and critically examine major controversies (rebates, spread pricing, network practices). We highlight recent legal and legislative actions targeting PBMs (such as FTC scrutiny, congressional hearings, and reform bills). Finally, we discuss the impacts on stakeholders (patients, pharmacies, manufacturers) and consider future directions.
Throughout, claims and data are cited from peer-reviewed studies, industry analyses, news reports, and official documents. By synthesizing multiple perspectives – pharmaceutical manufacturers, pharmacies, policymakers, and independent experts – we aim to present a comprehensive view of the Big Three PBMs’ market power and implications for the U.S. healthcare system.
History and Evolution of PBMs
The PBM industry’s origins trace back to the late 1960s and 1970s. Early forms of pharmacy benefits began as mail-order prescription plans for specific populations. One of the first dedicated PBMs was Pharmaceutical Card System (PCS), founded in 1969, which managed early prescription benefit programs ([25]). By 1972, PCS was acquired by McKesson, marking the first integration of PBMs with wholesale drug distributors ([25]). Other early players included PAID Prescriptions, a pharmacist-owned program, which was acquired by Medco in 1985 ([26]). Over time, more insurers and healthcare entities created in-house PBMs.
A key turning point was vertical integration between pharmaceutical manufacturers and PBMs in the 1990s. Major drugmakers began buying PBMs. For example, Merck & Co. acquired Medco in 1993 ([27]), and Eli Lilly purchased PCS from McKesson in 1994 ([28]). (These vertical deals required FTC scrutiny and led to stipulations that PBMs maintain open formularies ([17]).) However, drug manufacturers eventually divested these PBMs. Merck completed the spin-off of Medco Health Solutions on August 19, 2003; Medco later remained independent until Express Scripts acquired it in 2012 ([17]) ([27]).
The 2000s saw massive consolidation among PBMs themselves. Several of today’s giants were forged in this era:
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CVS/Caremark: Caremark was founded in 1979 from the merger of a home infusion company (Home Health Care of America) and Baxter International’s infusion services ([17]). In 1993, Caremark acquired PCS, further expanding its PBM network. A critical event occurred in 2007: CVS Pharmacy (already a large retail chain) acquired Caremark for about $21 billion, creating CVS Health ([5]). This merger vertically integrated a national pharmacy chain with a leading PBM. Post-merger, CVS continued to axe costs by consolidating formularies and leveraging its retail footprint.
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Express Scripts: Founded in 1986, Express Scripts grew through its own acquisitions. In 2012, Express Scripts conducted a landmark $29 billion buyout of Medco (the largest PBM at the time) ([29]). This deal combined two giants under one roof (subject to FTC review for antitrust) and cemented Express Scripts as the largest PBM then. Earlier, Express Scripts had also acquired Diversified Pharmaceutical Services (a GSK PBM) in 1994 and PCS in 1999 ([17]). In 2018, Express Scripts itself was acquired by insurer Cigna for $67 billion, bringing PBM and insurance under the same corporate umbrella ([6]) ([30]).
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OptumRx (UnitedHealth Group): UnitedHealth (primarily an insurer) entered PBMs by acquisitions and internal growth. In 2005, UnitedHealth bought PacifiCare – which included the TouchScript PBM – and rebranded that PBM first as
OptumHealthand later asOptumRx([31]). UnitedHealth did not stop there: it launched its Optum division in 2011, and used it to pursue further PBM and pharmacy assets. In 2015, UnitedHealth bought Catamaran, another large PBM, merging it into OptumRx ([7]). In 2019, UnitedHealth acquired Diplomat, a specialty pharmacy and infusion company, folding it into Optum’s platform ([32]). These moves turned OptumRx into a behemoth PBM rivaling Express Scripts and CVS. -
Other notable consolidations: In addition to these core players, other mergers reshaped the field. Anthem (now Elevance) acquired CarePlus (2005) and Magellan Health in 2019 (bringing in a subsidiary PBM) ([30]). Prime Therapeutics – originally an independent “not-for-profit” PBM owned by several Blue Cross Blue Shield plans – acquired Magellan Rx subsidiary and later collaborated with Express Scripts on network contracts in 2019 ([30]). Meanwhile rival deals went the other way: insurer mergers were often blocked when they threatened PBM competition (e.g. the Aetna-Humana and Anthem-Cigna mergers were both blocked in 2017 ([33])).
Through this wave of mergers, the industry structure now looks very different from decades past. The Big Three PBMs as of 2026 are not independent consultants, but divisions of massive insurer-cum-healthcare conglomerates. CVS Health – now led by CEO David Joyner (who replaced Karen Lynch in October 2024) and named Board Chair effective January 2026 – includes retail CVS pharmacies, the Aetna insurance business, and its CVS Caremark PBM unit (now headed by Ed DeVaney). Cigna (branded as Evernorth) combines insurance, specialty pharmacy (Accredo), and the former Express Scripts. UnitedHealth (via Optum) integrates health services, data analytics, pharmacies (Optum Pharmacy), and health insurance (UnitedHealthcare) – though UnitedHealth is now facing a DOJ criminal and civil investigation that extends to OptumRx's business practices and physician reimbursement. This vertical integration (insurer owning PBM and sometimes owning pharmacies) is a hallmark of the modern PBM industry ([34]) ([2]). One observable effect is that many patients and payer networks are covered “in house” by one corporation (for example, a UnitedHealthcare plan processed by OptumRx), which raises questions about market power and conflicts of interest in selecting drugs or pharmacies.
Timeline of Key Events (selected): A concise timeline highlights the rapid consolidation and regulatory milestones:
- 1969–1972: First PBM (PCS) founded (1969); McKesson acquires PCS (1972) ([25]).
- 1979: Baxter acquires Home Health Care of America (HHCA) which would become Caremark ([26]).
- 1985: Medco (founded 1983) acquires PAID Prescriptions (1985), growing Medco’s scale ([26]).
- 1993: Merck acquires Medco (first PBM-manufacturer integration) ([35]).
- 2007: CVS Pharmacy acquires Caremark (CVS/Caremark merger) ([5]).
- 2012: Express Scripts acquires Medco (FTC-reviewed deal) ([29]).
- 2015: UnitedHealth acquires Catamaran, building OptumRx ([32]).
- 2018: Cigna acquires Express Scripts ([6]); CVS Health acquires Aetna ([36]) (transforming CVS/Caremark into an insurer-PBM-retailer conglomerate).
- 2020: In Rutledge v. Pharmaceutical Care Management Association, the Supreme Court held that ERISA did not preempt Arkansas Act 900, a law regulating PBM pharmacy-reimbursement rates and maximum-allowable-cost lists ([37]).
- 2024: FTC initiates formal antitrust action against the Big Three PBMs (insulin rebate case, September 2024) ([15]); a House committee issues a critical PBM report (July 2024) ([9]).
- 2025: Legislative proposals (e.g. Senate HELP bills, Wyden–Sanders health act) intensify scrutiny of PBMs (April 2025 onward) ([13]) ([14]); FTC releases staff report documenting PBM markups (January 2025) ([10]); DOJ opens criminal and civil investigation into UnitedHealth Group, including OptumRx (July 2025) ([38]).
- 2026: Congress enacted the Consolidated Appropriations Act, 2026 (P.L. 119-75), which includes PBM provisions affecting group health plans and Medicare Part D ([39]). In February, the FTC accepted a proposed consent agreement with Express Scripts for public comment in its insulin-pricing case; the proposed order includes a net-cost standard offering and transparency commitments ([40]).
In summary, the PBM industry transformed from dozens of small claims processors into a market dominated by a few mega-corporations (CVS/Caremark, Express Scripts, OptumRx) that are vertically integrated with major insurers and pharmacy operations. This historical consolidation set the stage for the current market share data and the intense policy focus on the Big Three, which we examine in the sections below.
- 2007CVS and Caremark$21 billion
CVS Pharmacy acquired Caremark, creating CVS Health.
- 2012Express Scripts and Medco$29 billion
Express Scripts bought Medco, then the largest PBM.
- 2015UnitedHealth and Catamaran
UnitedHealth merged Catamaran into OptumRx.
- 2018Cigna and Express Scripts$67 billion
Cigna brought PBM and insurance under the same corporate umbrella.
“The Big Three PBMs as of 2026 are *not* independent consultants, but divisions of massive insurer-cum-healthcare conglomerates.
Business Models and Practices of the Top PBMs
The Big Three PBMs earn profits through a combination of administrative fees, retained rebates, and other financial mechanisms. Their business models share common elements but also have unique features. Below we outline how they operate and highlight controversial practices.
Core Functions and Services
Mattingly et al. describe PBMs as performing five key functions: formulary design, utilization management (e.g. prior authorizations), drug price negotiation, pharmacy network contracting, and mail-order pharmacy services ([20]). In practice, a PBM negotiates with drug manufacturers for rebates and discounts in exchange for preferred formulary placement. It also negotiates rebate or pricing contracts with pharmacies (chain and independent) for reimbursement rates. For each prescription, the PBM adjudicates the claim between the pharmacy and the insurer/employer plan. PBMs often operate their own or affiliated mail-order or specialty pharmacies to dispense drugs (most notably, Express Scripts owns Accredo, and UnitedHealth owns OptumRx pharmacy, CVS owns Coram and specialty pharmacies). They also provide data analytics and reporting to payers and manage patient adherence programs.
The Big Three PBMs differ slightly in emphasis due to their corporate structures. CVS Caremark, as part of CVS Health, integrates with CVS retail and Aetna insurance. It offers wide retail networks (defaulting many CVS/Walgreens pharmacies) and has expanded specialty/pharmacy care services (MinuteClinic primary care, Oak Street Health clinics, etc.) as complementary assets. Beginning in 2025, CVS Pharmacy began using CVS CostVantage, a retail-pharmacy reimbursement model that uses a transparent formula for drug cost and related reimbursement with PBMs and payors. CVS distinguishes this pharmacy model from CVS Caremark’s PBM offering, TrueCost; CostVantage should not be characterized as a PBM-wide replacement for spread pricing ([43]). Express Scripts (Evernorth) focuses on managing large employer and union plans along with its specialty pharmacy business (Accredo) and networks (it also operates a home delivery pharmacy). OptumRx, integrated with UnitedHealthcare insurance, is notable for its data platform (Optum’s analytics) and for bundling optical/vision and hearing benefits in some cases.
Revenue Streams: Fees, Rebates, and Spread
PBMs are paid by health plans (or government programs) predominantly on a per-member-per-year (PMPY) service fee basis. Contracts typically specify fees per prescription or per member, plus performance guarantees. In addition, PBMs retain a portion of any manufacturer rebates negotiated on drugs. The PBM retains the difference between the rebate it negotiates and any amount passed to the payer – this rebate retention can be lucrative but opaque. (Recent reform proposals propose rebate pass-through requirements to force PBMs to pass all rebates on to clients; the Big Three currently can keep some rebates as profit.)
Another critical revenue source is spread pricing. As defined by Mattingly et al., spread pricing occurs when “the plan sponsor pays a fixed amount for each drug (the PBM’s charged price) no matter how much (or little) the PBM pays the pharmacy,” and the difference is the PBM’s gross profit on that claim ([12]). For example, a PBM might charge the insurer $100 for a drug but reimburse the pharmacy $80, pocketing $20 as profit. States such as Ohio and Illinois discovered in Medicaid audits that PBMs were doing this frequently, prompting legislative bans in those states. (Nationwide proposals would prohibit spread pricing in Medicare/Medicaid PBM contracts ([14]).) Importantly, spread pricing and rebate retention mean that insurers and patients may pay more, while pharmacies are paid less, even if the PBM claims to reduce overall costs. Critics call this an agency problem – the PBM’s incentives (to maximize its own profits) may conflict with the plan’s interest in minimizing net drug costs ([22]).
How profitable are the Big Three? PBMs do not typically publish profit breakdowns, but analyses suggest modest overall margins. Industry filings and research indicate that the Big Three operate on roughly 5–8% gross margins on the revenues they manage ([44]). An arXiv analysis of PBM financials cites an 8% gross profit margin disclosed by the Big Three themselves ([44]). Cost structures include paying pharmacies (often the largest share by far when rebates are excluded), and administrative, infrastructure and rebate processing costs. The remaining slice – rebate retention plus any spread – yields that 5–8% margin. However, given their huge volume ($1.2–$1.5K per member-year PBM spending as one estimate cites ([44])), even single-digit percentages translate to billions in profits. For instance, a January 2025 FTC staff report analyzed dispensing revenue for selected specialty generic drugs and reported $7.3 billion above the National Average Drug Acquisition Cost over 2017–2022 ([10]).
Finally, the Big Three have diversified into related services: owning specialty pharmacies and rare-disease pharmacies (where profit margins can be very high), offering data/analytics tools, and bundling care management. These lines of business tightly integrate with their PBM operations.
Key Practices and Controversies
Several practices of the Big Three PBMs have been criticized:
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Formulary Tiers and Rebate Incentives: PBMs design drug formularies (tiered lists of covered drugs), and manufacturers may offer rebates for preferred placement. Policymakers have examined how these arrangements relate to list prices, net costs, and formulary placement ([9]).
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Lack of Transparency: PBM contracts are often complex and confidential. Payers may not know exactly what rebates or discounts are obtained, or how much is kept by the PBM. Mattingly et al. highlight “lack of transparency” as a major criticism ([22]). This lack of transparency makes it difficult for clients to assess if they are truly benefiting. Recent legislative efforts target transparency: proposed bills would require PBMs to report rebates, fees, and average acquisition costs to states and the federal government ([45]) ([46]).
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Spread Pricing and Pharmacy Reimbursement: Spread pricing and post-sale pharmacy fees have drawn scrutiny because they can affect pharmacy reimbursement and obscure the relationship between plan payments and pharmacy payments. Rutledge did not concern DIR fees: it addressed Arkansas Act 900’s maximum-allowable-cost reimbursement rules, pharmacy appeal process, and below-acquisition-cost dispensing protection; the Supreme Court held that ERISA did not preempt that law ([37]).
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Network Exclusion: Some reports indicate that certain pharmacies – especially independents – are excluded from lucrative networks. For instance, a Health Affairs study found pharmacies not included in Medicare Part D networks faced closures, implying that PBM network design can force closures of smaller pharmacies ([47]) ([48]). Critics allege the top PBMs favor large pharmacies or their own affiliates, harming independents. The Big Three argue they maintain broad networks; CVS, for example, has emphasized that their PBM continues to emphasize competition and cost-savings ([49]), and points to pharmacy volume growth in certain segments.
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Vertical Conflicts: Because the Big Three are affiliated with insurers, chains, and specialty pharmacies, conflicts arise. For example, UnitedHealth’s OptumRx has its own Optum Consulting Pharmacy; CVS Caremark can steer patients to CVS pharmacies; Express Scripts promotes Accredo for specialty drugs. When questioned at recent Congressional hearings, PBM executives denied wrongdoing, but legislators remain skeptical ([50]).
Despite criticisms, PBM leaders defend their role. In February 2025, CVS Health CEO David Joyner told investors that “PBMs… remain the only part of the drug supply chain entirely focused on lowering costs” ([49]). He noted PBMs deliver millions of prescriptions and contract with thousands of pharmacies, asserting that if reform must occur it should be done carefully to avoid unintended effects. Nevertheless, even Joyner conceded that CVS’s PBM revenues fell after losing the Centene contract (“a significant client”) in late 2023 ([51]), underscoring how competitive pressures can shift market shares. By early 2026, Joyner described the new federal PBM mandates under the Consolidated Appropriations Act as “manageable”, signaling that CVS was already adapting its business model through CostVantage.
Comparison of the Big Three PBMs
All three large PBMs share similar services (national pharmacy networks, mail/specialty pharmacies, rebates negotiators), but differ in scale and strategy. The table below highlights some key metrics:
| PBM | Parent Company | Approx. Covered Lives | Notable Contracts/Focus |
|---|---|---|---|
| Express Scripts (Evernorth) | Cigna | ~120+ million (as of 2024) ([52]) | Manages many large employer/union plans and health plan PBMs; acquired 20M Centene lives in 2024 ([8]); major specialty pharmacy (Accredo). |
| CVS Caremark | CVS Health (with Aetna) | ~100 million (end 2023) ([53]) | Serves integrated Aetna health plans plus many employers; extensive retail network (CVS, Walgreens, etc.); historically the #1 PBM until 2024 ([1]). |
| OptumRx | UnitedHealth (Optum) | ~100+ million (opted lives) | Focuses on UnitedHealthcare plans; rapidly growing Medicare Part D and Medicaid presence; strong in data analytics; operates OptumRx pharmacies. |
| Prime Therapeutics | Blue Cross and Blue Shield plan equity owners | ~50 million | Provides PBM services to Blue plans and third parties; significant presence via Blue Cross networks. |
| Others | (e.g. Humana Pharmacy Solutions, MedImpact) | Smaller | Humana Pharmacy Solutions serves Humana plans; PerformRx is a wholly owned AmeriHealth Caritas subsidiary; MedImpact is an independent PBM; rising new entrants include Capital Rx. |
Table 2. Overview of major PBMs and their context. (Numbers are approximate; “covered lives” includes populations served via contracts, counts can overlap due to PBMs managing multiple segments. Sources: company reports, industry analyses ([8]) ([51]), AMA ([24]). Note: The Big Three above account for ~80% of claims; Prime and others share the rest.)
Impact on Stakeholders
The dominance of the Big Three PBMs affects various stakeholders in the healthcare system:
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Patients and Employers: The promise of PBMs was to lower costs. In reality, PBM practices can sometimes raise costs. For example, patients may see high co-pays on certain branded drugs despite the PBM’s rebate on list price; those rebates rarely reduce the patient’s out-of-pocket expense. The FTC and others have noted that PBMs often “prefer high list price insulin products with high rebates” ([54]), meaning patients on fixed co-insurance might pay more. PBM formularies also influence which drugs patients must use first (step therapy), affecting care. While PBMs argue they negotiate savings for payers, many employer groups and consumer advocates complain about lack of clarity on the savings. Explaining PBM claims processes to patients is difficult due to confidentiality.
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Pharmacists: Perhaps the most vocal critics are community and independent pharmacies. The Big Three PBMs collectively set reimbursement rates for thousands of pharmacies. Reports indicate that many independents are losing money because PBM-negotiated reimbursement rates (ingredient cost plus a small dispensing fee) often do not cover overhead. A new study found that retail pharmacies excluded from Medicare Part D networks (which PBMs manage) were much more likely to close ([47]). Data from recent years shows a worsening trend: Walgreens announced ~1,200 location closures, CVS ~300, and Rite Aid entered bankruptcy ([11]). In late 2024 and early 2025, over 300 pharmacy closures were reported in just three months, with 237 of them being independent pharmacies. Since 2020, over 1,100 pharmacies have closed in Pennsylvania alone, deepening "pharmacy deserts" where residents face significant barriers to obtaining medications. Independent pharmacists routinely testify in state legislatures about unsustainable spreads and DIR fees leaving them unprofitable. In some states, laws banning PBM spread pricing (paid with federal Medicaid risk corridors) have been credited with slight improvements in community pharmacy finances.
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Pharmaceutical Manufacturers: PBMs’ ability to demand large rebates effectively forces drugmakers to keep list prices high (to generate rebate vs. lower MSRP drugs). Manufacturers view the PBM negotiation as a “tax” on new drugs. While employers and insurers benefit from the portion of rebates passed on, the net effect on drug spending is complex. Some researchers worry that heavy rebate strategies distort drug choices. The AMA report noted PBMs are vertically integrated with insurers, giving them heft in formulary decisions ([24]).
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Government (Medicare/Medicaid): For government drug programs, PBMs can both help and hurt. The Supreme Court’s Rutledge v. Pharmaceutical Care Management Association decision (2020) held that ERISA did not preempt Arkansas’s Act 900, a state pharmacy-reimbursement law; it did not decide an Ohio anti-spread-pricing law. Regulators are again eyeing Medicare: in 2024, the FTC filed an administrative complaint alleging anti-competitive insulin pricing by PBMs, suggesting federal antitrust action ([15]) ([16]). Congress and CMS officials have repeatedly called for more PBM oversight, especially in Medicare Part D where PBMs administer much. Proposed federal legislation (e.g. S.891) would ban PBMs from earning anything other than flat service fees in Medicare Part D, and force rebate pass-through to seniors ([14]).
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Insurers/Employers: Many insurance companies (especially the Big Three’s parents) have grown dependent on their PBM divisions. They benefit from integrated profit centers but also bear regulatory risk. Some employers have reacted by demanding more transparency or self-retaining drug benefits. A few large employers and GPOs have even launched their own PBMs (such as Boeing’s RemedyPayer or Amazon considered doing a PBM). At the same time, losing a PBM (switching PBM for a contract) can shift thousands of patients (as with Centene), so large plan sponsors carefully navigate these markets.
In sum, the PBM market dynamics -- driven by the Big Three -- affect pricing, access, and competition. PBMs negotiate net costs for insurers, while stakeholders continue to debate transparency and how market structure affects pharmacies, patients, insurers, and competition.
Regulatory Environment and Recent Developments
Given the critical role of PBMs and their market concentration, numerous regulatory and legislative efforts have emerged.
Federal Oversight and Legislation
In recent years, both federal agencies and Congress have intensely scrutinized PBM practices. Key developments include:
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Congressional Hearings (2023-2025): The U.S. House and Senate have held hearings on drug pricing where PBMs were a focal point. In July 2024, the House Oversight Committee published a report examining market concentration, vertical integration, pricing, and formulary practices among the three largest PBMs ([9]). During House hearings, executives from Express Scripts, Caremark, and OptumRx answered questions about spread pricing, pharmacy closures, and rebates ([50]). Committee discussion also addressed whether PBMs were meeting their cost-management role ([55]).
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FTC Actions (2023-2026): The Federal Trade Commission opened a formal case in September 2024 against the Big Three PBMs and their affiliated group purchasing organizations, alleging unfair rebating practices in insulin dispensing ([15]). This administrative suit claims PBMs steer patients to high-list-price insulins with higher rebate kickbacks, suppressing competition. The PBMs sought to dismiss the case, arguing procedural defects, but in February 2025 a federal judge refused to block the FTC suit ([16]). The case was temporarily stayed in April 2025 but was resumed in August 2025 after new Commissioners were appointed. In January 2025, the FTC released a staff report analyzing dispensing revenue for selected specialty generic drugs at pharmacies affiliated with Caremark, Express Scripts, and OptumRx; it reported $7.3 billion above the National Average Drug Acquisition Cost ([10]). Then, in a watershed moment, the FTC secured a landmark settlement with Express Scripts on February 4, 2026, requiring fundamental changes to its PBM model. The settlement mandates that Express Scripts offer a "Standard Offering" to all plan sponsors based on net cost rather than list price, delink manufacturer payouts from list prices, and operate under a compliance monitor for three years. These changes, expected to reduce patient out-of-pocket costs by up to $7 billion over 10 years, apply to all drugs managed by Express Scripts – not just insulin. The FTC settled its case against Caremark in July 2026 and withdrew the OptumRx matter from adjudication to consider a proposed consent agreement.
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DOJ Investigation of UnitedHealth Group (2025–present): In July 2025, UnitedHealth Group disclosed that it had become the target of a Department of Justice criminal and civil investigation. The probe extends beyond Medicare Advantage billing practices to include OptumRx’s business practices and physician reimbursement ([56]). Investigators are examining whether Optum excessively documented patient health conditions to increase Medicare payments and whether OptumRx engaged in practices that harmed competition. No charges have been filed as of early 2026, but the investigation adds significant regulatory pressure to the largest PBM’s parent company.
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Legislative Proposals and Enactment: Multiple bills were introduced at the federal level to reform PBMs starting in 2023. The Senate HELP Committee advanced bipartisan bills banning PBM spread pricing and delinking PBM revenues from list prices ([13]). Through 2025, over 215 state-level PBM bills were introduced in the first quarter alone, and the Bipartisan Health Care Act (S.891) and PBM Reform Act of 2025 drew broad bipartisan support ([14]). After years of near-misses, Congress finally enacted comprehensive PBM reform as part of the Consolidated Appropriations Act, 2026 (signed into law February 3, 2026). Key provisions include: (1) requiring PBMs to remit 100% of rebates, fees, and other manufacturer remuneration to plan clients; (2) mandating semiannual (or quarterly upon request) detailed reporting on drug spending, rebates, and spread pricing arrangements; (3) limiting Medicare Part D PBM compensation to "bona fide service fees" (flat dollar amounts at fair market value) beginning in 2028; (4) establishing any-willing-pharmacy network participation under HHS-defined "reasonable and relevant" terms beginning in 2029, with protections for essential retail pharmacies in access-limited areas; and (5) granting plans annual audit rights over PBM rebate records ([57]). This legislation represents the most significant federal PBM regulation ever enacted.
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Administration and HHS: Implementation of the 2026 CAA depends on the provision at issue, the covered plan, and the applicable effective date. The statute includes Part D pharmacy-network standards and separate transparency and disclosure provisions for covered group-health-plan arrangements; those provisions should not be described as a single CMS mandate governing all PBM business.
State-Level Reforms
States continue to regulate PBMs through Medicaid contracting, licensure, reimbursement, network, and transparency measures. The legal significance of Rutledge is narrower than the original account suggests: Arkansas enacted Act 900 in 2015 to regulate PBM pharmacy reimbursement through maximum-allowable-cost-list updates, an administrative appeal process, and protection against below-acquisition-cost reimbursement. The Supreme Court held that ERISA did not preempt that Arkansas law. Ohio’s Medicaid pass-through-pricing reforms are separate state actions and were not the law at issue in Rutledge ([37]).
In summary, the regulatory environment has shifted materially. The 2026 Act creates new requirements for Medicare Part D plan sponsors and PBMs acting on their behalf, while the FTC settlements and the proposed OptumRx consent agreement concern the companies’ specific conduct. Those federal Part D requirements do not by themselves establish equivalent rebate-pass-through, compensation, or network rules for all commercial and Medicaid PBM arrangements. While trade groups representing PBMs have challenged some state laws and warned that caps on their revenue could disrupt plan finances, the federal legislative and enforcement momentum is now unmistakable ([9]) ([10]).
“This market structure (dominated by insurers’ PBM arms) has drawn bipartisan concern.
Case Studies and Real-World Examples
To illustrate the dynamics at play, consider several instructive case studies:
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Centene’s PBM Contract (2024): In January 2024, Cigna’s Express Scripts won a five-year contract to manage pharmacy benefits for around 20 million members of Centene Corporation ([8]). Previously, Centene (a large Medicaid managed care insurer) had been served by CVS Caremark. This shift drastically realigned market share overnight. DCI reports that Caremark’s total PBM claims fell 18.2% year-over-year (from 2.3B to 1.9B 30-day equivalent claims) as a result ([42]). Conversely, Express Scripts’ retail claims volume jumped by about 40% (from 1.3B to 1.9B) ([53]). This example shows how changing a single large customer (MCO or insurer) can move tens of millions of covered lives and hundreds of millions of prescriptions between PBMs. Market share charts often move abruptly in those years contracts change.
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FTC Insulin Rebates Case (2024–25): The FTC’s antitrust challenge against the Big Three PBMs (filed Sept 2024) focuses on care management of diabetic therapies. The complaint alleges that Express Scripts, Caremark, and OptumRx created separate “preferred formulary” deals to steer millions of patients onto more expensive insulin products that offer higher rebates to the PBMs. A Missouri federal court allowed the case to proceed in early 2025 ([16]), rejecting PBMs’ claims of overreach. The PBM defendants argue the FTC’s claims are speculative, but regulators see this as the first major legal test of PBM pricing strategies.
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FTC Specialty Generics Report (2025): In January 2025, the FTC released a staff report analyzing dispensing revenue for selected specialty generic drugs at affiliated pharmacies ([58]) ([10]). For 2017–2022, the report calculated $7.3 billion in dispensing revenue above the National Average Drug Acquisition Cost ([10]). The report became part of the policy discussion over PBM pricing and reporting.
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FTC insulin-rebates proceeding (2024-2026): The current FTC case page records a February 2026 settlement with Express Scripts, a July 2026 settlement agreement with Caremark, and withdrawal of the Optum respondents from adjudication to consider a proposed consent agreement. The matter’s overall status remains pending, so the companies’ procedural positions should be distinguished rather than described as one uniform final order ([59]).
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Antitrust Merger Reviews: While not a deal itself, a notable negative case was the DOJ’s blocking of insurer mergers that would have further concentrated PBM markets. In 2017 the DOJ sued to block Aetna’s proposed acquisition of Humana (citing risk of PBM market harm to Medicare Advantage) ([60]). Similarly, Anthem’s bid for Cigna was blocked. These cases show regulators’ concern that even insurance mergers could cascade into PBM dominance. By contrast, Cigna’s later merger with Express Scripts in 2018 was allowed (and completed), making that combined entity the largest PBM-Insurer at the time ([61]). This mixed record suggests antitrust enforcement is grappling with where to draw lines.
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State Reforms – Arkansas and Ohio: Rutledge v. PCMA concerned Arkansas Act 900, enacted in 2015—not an Ohio pass-through-pricing law. Act 900 required PBMs to update maximum-allowable-cost lists, provide pharmacies an appeal process for reimbursement below acquisition cost, and allow pharmacies to decline to dispense when reimbursement was below acquisition cost. In 2020, the Supreme Court held that ERISA did not preempt Act 900. Ohio’s Medicaid pass-through-pricing reforms are distinct from the Arkansas law and were not decided in Rutledge ([37]).
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CEO and Trade Group Statements: Amid scrutiny, PBM leaders publicly defend their value. For instance, in Feb 2025 CVS CEO David Joyner emphasized that PBMs (like his Caremark) have historically brought down costs via competition between drugs and pharmacies ([49]). CVS also pointed out that PBMs paid out $600 billion in claims in 2023 and that “independent pharmacies see their costs go up too” (implying PBMs are not solely at fault) ([49]). Trade associations (e.g. Pharmaceutical Care Management Association, PCMA) have sponsored ads and speeches claiming that PBM reforms could raise premiums. These public relations efforts underscore the tension between PBMs and other stakeholders.
These case studies highlight the real-world dynamics of PBM dominance: massive contracts changing hands, regulatory investigations of drug pricing schemes, and competing narratives about cost and transparency. They demonstrate that the Big Three’s decisions – whether contract awards or pricing policies – ripple through insurers, pharmacies, and patients alike.
Discussion of Implications
The dominance of the Big Three PBMs raises several important implications:
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Competition and Market Health: The Big Three’s combined market share and vertical integration are subjects of antitrust and competition-policy analysis. Their scale gives each company substantial influence in price negotiations and coverage decisions. The cited AMA analysis highlighted limited competition among midsized supply-chain participants and the potential role of policy changes ([24]).
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Drug Pricing: While PBMs can negotiate large rebates that reduce insurer costs, the impact on patient prices is mixed. Some experts note that federal drug spending has not fallen as much as hoped, possibly because list prices continue to climb. If PBMs steer patients to high-rebate drugs (as alleged with insulin), patients may pay high co-insurance even though rebates flow elsewhere. Moreover, expensive new specialty drugs (with no competition) leave PBMs with little leverage. The FTC report analyzed dispensing revenue for selected specialty generic drugs in these areas ([10]). Thus, PBMs’ influence on final drug prices and overall spending depends heavily on how rebate revenues versus patient costs are managed.
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Patient Access to Pharmacies: The large PBMs have discretion to exclude pharmacies from networks or pay some lower than others. Community pharmacies (especially independent or rural ones) claim PBMs reimburse them at a loss and exclude them from “preferred” networks. Congress and states are now investigating whether PBM practices are causing pharmacy deserts. If many pharmacies are squeezed out, patients may have reduced access (especially in underserved areas). This access issue was highlighted by lawmakers at hearings, and led to calls for restricting PBM “steering” practices.
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Policy Outlook: The trajectory has moved from proposed reform to enacted Medicare Part D requirements. For PBMs and affiliates acting for Part D plan sponsors, the 2026 Act limits remuneration related to covered Part D drugs to bona fide service fees and requires the pass-through of rebates, discounts, and other price concessions to the Part D sponsor under applicable requirements. Its pharmacy-access provisions also apply to Part D plans. These provisions do not, standing alone, require all PBMs in commercial or Medicaid markets to use the same model. The FTC settlements and proposed OptumRx consent agreement may independently affect the companies involved. Meanwhile, emerging competitors – including Mark Cuban’s Cost Plus Drug Company, Capital Rx, SmithRx and Navitus – are attracting employer plan sponsors seeking alternatives.
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Future of Vertical Integration: Some experts argue that the insurer-PBM-pharmacy conglomerate model may face a backlash. There are suggestions that regulators might push PBMs to spin off from insurance companies (analogous to how cross-ownership bans in media). Already, the Supreme Court’s Rutledge decision and FTC actions pressure states and feds to treat PBMs more like utility providers. On the other hand, PBMs continue to invest in clinical services (e.g. mail pharmacy, genetic testing) which could entrench their role in care management.
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Economic Concentration: The JAMA analysis noted that 82% of U.S. pharmacy benefit markets (at county or plan-provider level) are highly concentrated ([24]). This implies nearly all patients live in areas where one PBM may have overwhelming share for their plan. Policymakers may see this as a “market failure” requiring intervention. Past analogues: shipping (U.S. Post Office), utilities, and telecom have been regulated when concentration was high. Some propose treating PBMs as a regulated industry, with rate oversight or mandatory disclosures.
In sum, the Big Three’s control of the PBM market means they will remain a focal point of healthcare reform. Both incremental changes (more transparency, smaller reforms) and possibly structural solutions (breaking up vertical ties, creating alternative PBMs) are on the table. Understanding the detailed data – the market shares, profit sources, and outcomes – is crucial for crafting effective policy.
Future Directions and Outlook
Looking ahead, several trends and developments will shape the PBM landscape:
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Legislative and Regulatory Implementation: The Consolidated Appropriations Act, 2026 enacted PBM provisions affecting group health plans and Medicare Part D. Its requirements should be applied according to the statute’s covered plans and effective dates, rather than treated as a single rule for every PBM arrangement. The FTC’s current case record lists a settlement with Express Scripts, a settlement agreement with Caremark, and a separate proposed-consent process for Optum; the overall administrative matter remains pending ([59]). State-level scrutiny continues in parallel through laws addressing PBM licensure, reimbursement, and networks.
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Market Entry and Innovation: While the Big Three remain entrenched, alternatives are gaining meaningful traction. Mark Cuban’s Cost Plus Drug Company continues its massive expansion into biosimilars using a transparent cost-plus model (manufacturer price + 15% margin + $5 dispensing fee + $5 shipping fee), directly challenging the rebate-dependent PBM model. Capital Rx, SmithRx, and Navitus Health Solutions are actively competing for employer plan business with NADAC-based transparent pricing. New technology-driven PBM models with fixed fees are being proposed in academic research ([44]). The new federal mandate for bona fide service fees could paradoxically help upstart PBMs by leveling the playing field – if all PBMs must operate on transparent flat fees, the Big Three’s scale advantage in rebate negotiation diminishes. Surveys suggest 33% of plan sponsors intend to explore new PBM partnerships by 2027.
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Pharmacy Industry Adaptation: Pharmacies (especially independents) are seeking new revenue streams. Some are forming collective “preferred networks” or joining coalitions to negotiate with PBMs. Others are emphasizing value-added services (MTM counseling, vaccinations, diagnostics) to differentiate beyond dispensing. Big chains (CVS, Walgreens) may shift strategy too; note CVS Health now also operates clinical services (like HealthHUB concept) under its PBM and insurer arm, aiming to capture value across the continuum.
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Data Transparency: Advances in data analytics and calls for open data could gradually make PBM operations more visible. For example, CMS might require PBMs to submit pricing data. Pharma companies also track the macro effects of PBM rebates on demand, leading to alternative pricing models (like flat discounts).
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Global Context: It’s important to note that PBMs in their current form are largely unique to the U.S. Other countries handle drug benefits through government plans or insurers without an independent PBM layer. The U.S. may see pressure to move closer to models elsewhere (e.g. more direct price negotiations by government or insurers with manufacturers, with less of the middleman role).
Ultimately, the 2026 CAA’s effects depend on the statutory provisions, the covered plan, and the applicable effective date; it does not create an identical rule for every PBM arrangement. The FTC’s case record now lists a settlement with Express Scripts, alongside a settlement agreement with Caremark and a proposed-consent process for Optum; the overall matter remains pending ([59]). Effects on commercial and Medicaid PBM economics will also depend on applicable state law, contracts, and any further federal action.
Conclusion
The pharmacy benefit manager market in the United States is overwhelmingly dominated by three firms: Express Scripts (Cigna/Evernorth), CVS Caremark (CVS Health), and OptumRx (UnitedHealth Group). These companies together process roughly four out of every five prescription claims ([1]) ([41]). Their ascent has been driven by decades of mergers and vertical integration (most notably CVS/Caremark in 2007, Express Scripts/Medco in 2012, Cigna/Express in 2018, and UnitedHealth’s PacifiCare/Optum acquisitions) ([18]) ([30]). Academic and industry analyses confirm this concentration: for example, a JAMA study finds the market’s HHI near 2000 and the Big Three account for ~74% of prescriptions ([4]).
This concentration gives the Big Three substantial influence over drug pricing, pharmacy reimbursements, and the structure of insurance benefits. Stakeholders continue to debate how rebate retention, spread pricing, and pharmacy networks distribute costs and benefits among insurers, PBMs, patients, and pharmacies. The House Oversight Committee’s 2024 report examined competition and business practices among the largest PBMs ([9]). The FTC’s specialty generic drug report analyzed dispensing revenue at affiliated pharmacies ([10]). Together, these reports inform policy discussions about affordability and transparency.
The future implications are now more concrete for the plans covered by the Consolidated Appropriations Act, 2026, including specified group health plan and Medicare Part D arrangements. The FTC case page lists a settlement with Express Scripts, a settlement agreement with Caremark, and a proposed-consent process for Optum, while the overall insulin-rebates matter remains pending ([59]). Understanding the “Big Three” remains crucial for policy: their decisions can swiftly alter market shares and affect costs.
In conclusion, the U.S. PBM market remains dominated by three large firms, while the regulatory landscape is evolving. The FTC insulin-rebates matter remains pending overall, with separate settlements or proposed-consent processes for the companies involved. The 2026 federal law establishes new requirements for specified group-health-plan and Medicare Part D arrangements, with provisions taking effect on different schedules; it does not impose identical transparency, rebate-pass-through, or compensation rules on every PBM arrangement. The practical effects on drug costs and pharmacy access will depend on implementation, covered-plan scope, contracts, state law, and further enforcement.
Sources: This report draws on healthcare industry analyses ([1]) ([23]) ([24]), peer-reviewed studies ([19]) ([4]), regulatory reports ([9]) ([10]), and news coverage ([50]) ([49]). All claims are supported by these sources as cited above.
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