It’s becoming less common for employers to contract with one of the Big Three pharmacy benefit managers, according to a new survey from the National Alliance of Healthcare Purchaser Coalitions.
The survey of 408 employers found that the share of employers contracting with one of the Big Three dropped from 63.4% in 2025 to 54.3% in 2026. The Big Three include Optum Rx, CVS Caremark and Express Scripts.
This drop was mainly driven by employers with fewer than 1,000 employees. Of those who are currently Big Three clients, 55.7% said they’re considering changing PBMs within the next one to three years, versus 31.1% of employers contracting with other PBMs. Employers with 10,000 or more employees are the slowest to adopt alternative PBMs, but have the greatest interest in switching vendors in the next three years, according to the survey.
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“Large employers show the strongest interest in changing PBMs, but they have moved the least so far,” the report said. “That gap may reflect the scale of the decision: Larger organizations often use formal procurement cycles and need more time to evaluate pricing, operations, and member impact before making a change.”
The National Alliance also found that PBM reform was the “most helpful policy reform tested in the survey.” About 87.6% of employers said PBM reform would be very or somewhat helpful, followed by 84.6% who said hospital price transparency and 83.8% who said drug price regulation.
To improve transparency, many employers have adopted contracts with PBMs that require 100% of rebates to be passed through. Some employers are also requiring no spread pricing and disclosure of affiliated entities.
About 23% of Big Three clients, however, said they’re “not sure” what’s in their contracts, compared with 12% of those using other PBMs.
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Additional findings from the survey include:
- Affordability is a main concern for employers. Employers project that healthcare costs will rise by an average of 7.7% before making plan design changes next year.
- Employers report that drug prices (77%), high-cost claims (75%) and hospital prices (68%) are the top threats. Employers estimate that hospital and facility costs account for 30.5% of total healthcare spending, followed by prescription drugs at 21.1% and professional fees at 19.1%.
- Employers are more likely to take action on healthcare costs when they have detailed access to their healthcare claims data. Employers with full access to claims data implemented nearly four more cost-saving and value-focused strategies on average than those with limited or no access (11.9 versus 7.9).
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