The top four PBMs controlled 75% of the national PBM market in 2024, up from 70% in 2022, according to a new analysis from the American Medical Association.
The analysis is based on prescription drug plan and enrollment data from 2022 and 2024. It looked at market shares of the 10 largest PBMs.
The four largest PBMs by national market share in 2024 were OptumRx (23%), Express Scripts (23%), CVS Caremark (18%) and Prime Therapeutics (11%). This compares to 2022, when the ranking was CVS (21%), OptumRx (21%), Express Scripts (17%) and Prime Therapeutics (10%). Express Scripts had the largest increase between these two time periods.
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The report also found that 32 of PBM markets, or 94%, were highly concentrated in 2024, compared to 28 (82%) in 2022.
In addition, each of the 10 PBMs listed in the report has a shared ownership with health insurers. In 2024, 69% of people with commercial or Medicare Part D drug coverage were enrolled with an insurer that was vertically integrated with a PBM. Vertical integration between insurers and PBMs varied widely across local markets, with some having little vertical integration and others being almost entirely vertically integrated.
The analysis also looked at national market shares for the 10 largest insurers providing prescription drug benefits. It found that UnitedHealth Group had the largest market share in commercial and Medicare Advantage PDP coverage, while Centene led the stand-alone Medicare Part D market. Kaiser and Humana ranked second in the commercial and Medicare Advantage PDP markets, respectively, while CVS Health (Aetna) ranked second in the stand-alone market.
“Competitive PBM and prescription drug plan markets help patients get the medications they need at a fair price,” said AMA President Dr. Willie Underwood III, in a statement. “But our analysis shows that a small number of PBMs account for a growing share of the market, while most local PBM markets remain highly concentrated and most prescription drug benefits are managed by vertically integrated insurers and PBMs.”
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There have been several efforts to crack down on PBMs recently. In February, Congress passed reforms like delinking PBM compensation from the price of a drug in Medicare Part D. A proposed Department of Labor rule also seeks to improve transparency in fees and compensation received by PBMs.
The American Medical Association hopes to see more efforts to rein in PBMs.
“These trends warrant closer scrutiny, greater transparency and stronger accountability to ensure PBM markets serve patients rather than reinforce the market power of large healthcare companies,” Underwood said.
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