Pharmacy Benefit Management Market in US - Industry Outlook and Forecast 2020-2025

Pharmacy Benefit Management Market in US - Industry Outlook and Forecast 2020-2025

In-depth Analysis and Data-driven Insights on the Impact of COVID-19 Included in this US Pharmacy Benefit Management Market Report

The pharmacy benefit management market in US is expected to grow at a CAGR of over 7% during the period 2019–2025.

The U.S. healthcare landscape is complex. It is riddled with wastage, drug abuse, and fraud due to a whirlwind of causative factors, putting patients at risk and creating a dilemma for insurers. It translates to high out-of-pocket costs, increased incidences of inappropriate spending, higher premiums, reduced benefits or coverage for consumers, increases cost of doling out insurance benefits for governments, and private employers. With a high number of consumers being enrolled in high-deductible health plans, there is a need for coordinated and broad effort to fix loopholes. Pharmacy benefit managers are well-positioned as patients advocate to work with players across the board, with every member in the healthcare industry. PBM pharmacists can witness a complete picture of the member’s medication background. This has enabled them to drive awareness among pharmacists and doctors/physicians to identify challenges and enable the delivery of better treatment through better communication and care coordination across the healthcare continuum for each patient.

The following factors are likely to contribute to the growth of the pharmacy benefit management market in US during the forecast period:
Foray into Digital Health Solutions
Growth in FDA Approvals for Orphan and Specialty Drugs
Shift to Value/Outcomes-based Contracts
Increased Engagement in High-touch Care Management

The study considers the present scenario of the pharmacy benefit management market in US and its market dynamics for the period 2019−2025. It covers a detailed overview of several market growth enablers, restraints, and trends. The study offers both the demand and supply aspects of the market. It profiles and examines leading companies and other prominent ones operating in the market.

PHARMACY BENEFIT MANAGEMENT MARKET IN US : SEGMENTATION

This research report includes a detailed segmentation by services, health plan, and business model. Specialty pharmacy - a segment of the U.S. Pharmacy Benefit Management market, which is a collaborative, clinical, integrated environment, is recording significant growth in the US pharmacy benefit management market. The segment has cemented its place in the continuum of healthcare, backed by a healthy level of activity in payer access and data systems. As specialty drugs have outpaced all the other elements of healthcare costs, the segment is keeping payers’ on the edge of their seats. Since specialty pharmacies and mail-order pharmacies operate on a similar model in terms of medication deliveries. There are apprehensions about conflicts of interest and about how PBMs tag specific drugs as “specialty.”
Drugs, which treat auto-immune conditions, are growing at the fastest rate in commercial health plans. With emerging therapies that come at a high cost, the per-member, per-month spending on these therapies has witnessed an upward trend over the past couple of years. The increased focus of commercial health plan providers is on monitoring use and keeping the cost of drugs in check. This has led to an increased focus on utilization monitoring and formulary design, driving better prospects for the segment.
Commercial plan sponsors are also looking to increase resources to help employees access behavioral and mental health services as they struggle with maintaining the usefulness of prescription management services. The enrollment in Medicare Part D plans has grown 2X times over the last 15 years. Seeing as Medicare is designed to absorb risk, providing for individuals with complex, expensive medical needs, along with relatively healthy individuals, these plans rely heavily on PBMs.
The Pharmacy benefit management market in US is well backed, fortifying future growth by ramping up the capital investment in data analytics capabilities and technology R&D. As employers continue to concentrate on whole-person health, providing a total benefits solution, which is vital to draw and keep talent, this segment is expected to grow.
As insurance companies launch new products for gene therapies, they are considering offering therapy management techniques. The key players in the market are keeping a tab on the gene therapy pipeline and tracing patient outcomes, which are being used as a starting point for value-based arrangements that the company is on with pharma manufacturers. This is drawing attention, particularly from employers, creating favorability for players with these business models. The pharmacy benefit management market in US is highly fragmented.

By Health Plans
Commercial Health Plan
Self-insured Employer Plan
Medical Part D Plans
Managed Medicaid Programs
Other
By Services
Specialty Pharmacy Services
Retail Pharmacy Services
Mail-order Pharmacy Services
Benefit Plan Design & Administration
Formulary Management
Clinical Programs & Services
Others
By Business Model
Insurance Companies & Retail Pharmacies
Pure Play PBMs

INSIGHTS BY VENDORS
The Pharmacy Benefit Management market in US share has changed considerably in the last couple of years, where acquisitions led the market to where it is today, occupied mostly by a couple of giants. As a result, the PBM industry is highly concentrated with Caremark, Express Scripts, and OptumRX, accounting for more than 70% of claims volume. They have been the shapeshifters in the PBM space. However, that again is changing as insurers have been building their presence in the market by dissolving existent relationships with PBMs and acquiring or launching their own.

Key Vendors
CVS Caremark
Express Scripts
OptumRx
Humana Pharmacy Solutions
ther Prominent Vendors
Abarca Health
Anthem
AscellaHealth
BeneCard PBF
Centene
Citizens Rx
EnvisionRxOptions
Excelera
Magellan Rx Management
MedalistRx
MedImpact
Prime Therapeutics
MaxorPlus
Navitus Health Solutions
Perform Rx
RxAdvance
WellDyneRx

KEY QUESTIONS ANSWERED
1. What is the U.S. Pharmacy Benefit Management Market Size in 2020?
2. What is the growth rate (CAGR) of the U.S. PBM Market during 2020-2025
3. Which are the leading segment of the U.S. PBM Market?
4. Impact of COVID-19 on the Pharmacy Benefits Management Market in the U.S.?


1 Research Methodology
2 Research Objectives
3 Research Process
4 Scope & Coverage
4.1 Market Definition
4.1.1 Inclusion
4.1.2 Exclusion
4.2 Base Year
4.3 Scope Of The Study
4.4 Market Segments
4.4.1 Market Segmentation By Service
4.4.2 Market Segmentation By Health Plan
4.4.3 Market Segmentation By Business Model
5 Report Assumptions & Caveats
5.1 Key Caveats
5.2 Currency Conversion
5.3 Market Derivation
6 Market at a Glance
7 Introduction
7.1 State of the US Economy and healthcare industry
7.2 Pharmacy Benefits Management
7.2.1 Benefits
7.2.2 Value Chain
7.2.3 PBM Financial Arrangements
7.2.4 Success Factors
8 Growth Opportunities & Trends
8.1 Foray into Digital Health Solutions
8.2 Shift to Value / Outcomes-based Contracts
8.3 Move Away From a Standalone Mentality
8.4 Increased Engagement in High-Touch Care Management
9 Market Growth Enablers
9.1 Gaps in Information and Care in the Healthcare Industry
9.2 Growth in FDA Approvals for Orphan and Specialty Drugs
9.3 Prevalence of Fraud, Waste, and Abuse in Healthcare
9.4 Shift Towards Individualized Medicines
10 Market Restraints
10.1 PBMs Maligned And Scrutinized For Pricing
10.2 Declining Growth From Generics
10.3 Legal Uncertainty & Impending Limitations On PBM Tools
10.4 Significant Delays Cause Dissatisfaction
11 Market Landscape
11.1 Market Size & Forecast
11.2 Five Forces Analysis
11.2.1 Threat of New Entrants
11.2.2 Bargaining Power of Suppliers
11.2.3 Bargaining Power of Buyers
11.2.4 Threat of Substitutes
11.2.5 Competitive Rivalry
12 Service
12.1 Market Snapshot & Growth Engine
12.2 Market Overview
12.3 Specialty Pharmacy Services
12.3.1 Market Size & Forecast
12.4 Retail Pharmacy Services
12.4.1 Market Size & Forecast
12.5 Mail-order Pharmacy Services
12.5.1 Market Size & Forecast
12.6 Benefit Plan Design and Administration
12.6.1 Market Size & Forecast
12.7 Formulary Management
12.7.1 Market Size & Forecast
12.8 Clinical Programs and Services
12.8.1 Market Size & Forecast
12.9 Others
12.9.1 Market Size & Forecast
13 Health Plan
13.1 Market Snapshot & Growth Engine
13.2 Market Overview
13.3 Commercial Health Plans
13.3.1 Market Size & Forecast
13.4 Medicare Part D Plans
13.4.1 Market Size & Forecast
13.5 Self-insured Health Plans
13.5.1 Market Size & Forecast
13.6 Managed Medicaid Programs
13.6.1 Market Size & Forecast
13.7 Others
13.7.1 Market Size & Forecast
14 Business Model
14.1 Market Snapshot & Growth Engine
14.2 Market Overview
14.3 Insurance Companies and Retail Pharmacies
14.3.1 Market Size & Forecast
14.4 Pure Play PBMs
14.4.1 Market Size & Forecast
15 Competitive Landscape
15.1 Competitive Scenario
16 Market Vendor Analysis
16.1 Market Ranking Analysis
17 Key Company Profiles
17.1 CVS Caremark
17.1.1 Business Overview
17.1.2 Major Service Offerings
17.1.3 Key Strengths
17.1.4 Key Strategies
17.1.5 Key Opportunity
17.2 EXPRESS SCRIPTS
17.2.1 Business Overview
17.2.2 Major Service Offerings
17.2.3 Key Strengths
17.2.4 Key Strategies
17.2.5 Key Opportunity
17.3 OPTUMRX
17.3.1 Business Overview
17.3.2 Major Service Offerings
17.3.3 Key Strength
17.3.4 Key Strategies
17.3.5 Key Opportunity
17.4 Humana Pharmacy Solutions
17.4.1 Business Overview
17.4.2 Major Service Offerings
17.4.3 Key Strengths
17.4.4 Key Strategies
17.4.5 Key Opportunity
18 Other Prominent Vendors
18.1 Abarca Health
18.1.1 Business Overview
18.1.2 Service Offerings
18.1.3 Key Strengths
18.1.4 Key Strategies
18.2 Anthem
18.2.1 Business Overview
18.2.2 Service Offerings
18.2.3 Key Strengths
18.2.4 Key Strategies
18.3 Ascella Health
18.3.1 Business Overview
18.3.2 Service Offerings
18.3.3 Key Strengths
18.3.4 Key Strategies
18.4 BeneCard PBF
18.4.1 Business Overview
18.4.2 Service Offerings
18.4.3 Key Strengths
18.4.4 Key Strategies
18.5 Centene
18.5.1 Business Overview
18.5.2 Service Offerings
18.5.3 Key Strengths
18.5.4 Key Strategies
18.6 Citizens Rx
18.6.1 Business Overview
18.6.2 Service Offerings
18.6.3 Key Strengths
18.6.4 Key Strategies
18.7 EnvisionRxOptions
18.7.1 Business Overview
18.7.2 Service Offerings
18.7.3 Key Strengths
18.7.4 Key Strategies
18.8 Excelera
18.8.1 Business Overview
18.8.2 Service Offerings
18.8.3 Key Strengths
18.8.4 Key Strategies
18.9 Magellan Rx Management
18.9.1 Business Overview
18.9.2 Service Offerings
18.9.3 Key Strengths
18.9.4 Key Strategies
18.10 MedalistRx
18.10.1 Business Overview
18.10.2 Service Offerings
18.10.3 Key Strength
18.10.4 Key Strategies
18.11 MedImpact Healthcare Systems
18.11.1 Business Overview
18.11.2 Service Offerings
18.11.3 Key Strengths
18.11.4 Key Strategies
18.12 Prime Therapeutics
18.12.1 Business Overview
18.12.2 Service Offerings
18.12.3 Key Strengths
18.12.4 Key Strategies
18.13 MaxorPlus
18.13.1 Business Overview
18.13.2 Service Offerings
18.13.3 Key Strengths
18.13.4 Key Strategies
18.14 Navitus Health Solutions
18.14.1 Business Overview
18.14.2 Service Offerings
18.14.3 Key Strength
18.14.4 Key Strategy
18.15 Perform Rx
18.15.1 Business Overview
18.15.2 Service Offerings
18.15.3 Key Strengths
18.15.4 Key Strategies
18.16 RxAdvance
18.16.1 Business Overview
18.16.2 Service Offerings
18.16.3 Key Strengths
18.16.4 Key Strategies
18.17 WellDyne RX
18.17.1 Business Overview
18.17.2 Service Offerings
18.17.3 Key Strengths
18.17.4 Key Strategies
19 Report Summary
19.1 Key Takeaways
19.2 Strategic Recommendations
20 Quantitative Summary
20.1 Market By Service
20.2 Market BY Health Plan
20.1 Market By Business Model
21 Appendix
21.1 Abbreviations
List of Exhibits
Exhibit 1 Segmentation of Pharmacy Benefit Management Market in US
Exhibit 2 Market Size Calculation Approach 2019
Exhibit 3 Prescription Drug Expenditures 2011−2027 ($ billions)
Exhibit 4 Number of Drug Approvals in the Pipeline for 2020
Exhibit 5 Pharmacy Benefits Management Value Chain
Exhibit 6 Impact of Foray into Digital Health Solutions
Exhibit 7 Impact of Shift to Value/Outcomes-based Contracts
Exhibit 8 Impact of Move Away from a Standalone Mentality
Exhibit 9 Impact of Increased Engagement in High-touch Care Management
Exhibit 10 Impact of Gaps in Information and Care in the Healthcare Industry
Exhibit 11 US Medication Nonadherence Statistics 2019
Exhibit 12 Impact of Growth in FDA Approvals for Orphan and Specialty Drugs
Exhibit 13 Impact of Prevalence of Fraud, Waste, and Abuse in Healthcare
Exhibit 14 Overview of Fraud, Waste, and Abuse in the US 2019
Exhibit 15 Impact of Shift towards Individualized Medicines
Exhibit 16 Impact of PBMs Maligned and Scrutinized for Pricing
Exhibit 17 Impact of Declining Growth from Generics
Exhibit 18 Share of Generic versus Branded Drug Prescriptions Dispensed in the US 2008−2018
Exhibit 19 Impact of Legal Uncertainty & Impending Limitations on PBM Tools
Exhibit 20 Impact of Significant Delays Cause Dissatisfaction
Exhibit 21 The Case for PBMs
Exhibit 22 Pharmacy Benefit Management Market in US 2019–2025 ($ billion)
Exhibit 23 Five Force Analysis 2019
Exhibit 24 Incremental Growth by Service 2019 & 2025
Exhibit 25 Pharmacy Benefit Management Market in US by Service ($ billion)
Exhibit 26 Pharmacy Benefit Management Market in US by Service 2019 & 2025 (% share)
Exhibit 27 Statistics on Specialty Drugs in US 2019
Exhibit 28 Pharmacy Benefit Management Market in US by Specialty Pharmacy Services 2019–2025 ($ billion)
Exhibit 29 Pharmacy Benefit Management Market in US by Retail Pharmacy Services 2019–2025 ($ billion)
Exhibit 30 Pharmacy Benefit Management Market in US by Mail Order Pharmacy Services 2019–2025 ($ billion)
Exhibit 31 Pharmacy Benefit Management Market in US by Benefit Plan Design and Administration 2019–2025 ($ billion)
Exhibit 32 Pharmacy Benefit Management Market by Formulary Management in US 2019–2025 ($ billion)
Exhibit 33 Employer Plan Sponsors’ Use of Utilization Management Tools 2019
Exhibit 34 Pharmacy Benefit Management Market by Clinical Programs and Services in US 2019–2025 ($ billion)
Exhibit 35 Pharmacy Benefit Management Market by Others in US 2019–2025 ($ billion)
Exhibit 36 Incremental Growth by Health Plan 2019 & 2025
Exhibit 37 Pharmacy Benefit Management Market in US by Health Plans 2019−2025 ($ billion)
Exhibit 38 Pharmacy Benefit Management Market in US by Health Plans 2019 and 2025 (% share)
Exhibit 39 Pharmacy Benefit Management Market in US - Comparison by Health Plan 2019−2025 (% share)
Exhibit 40 Future Prospects of PBM Service and Tool Utilization by Commercial Health Plan Payers
Exhibit 41 Pharmacy Benefit Management Market in US by Commercial Health Plans 2019–2025 ($ billion)
Exhibit 42 Pharmacy Benefit Management Market in US by Medicare Part D Plans 2019–2025 ($ billion)
Exhibit 43 Pharmacy Benefit Management Market in US by Self-insured Health Plans 2019–2025 ($ billion)
Exhibit 44 Self-insured Employer Priorities and Areas of Focus to Manage Costs 2019−2025
Exhibit 45 Pharmacy Benefit Management Market in US by Managed Medicaid Programs 2019–2025 ($ billion)
Exhibit 46 Pharmacy Benefit Management Market in US by Others 2019–2025 ($ billion)
Exhibit 47 Incremental Growth by Business Model 2019 & 2025
Exhibit 48 Pharmacy Benefit Management Market in US by Business Model 2019−2025 ($ billion)
Exhibit 49 Pharmacy Benefit Management Market in US by Business Model 2019 and 2025 (% share)
Exhibit 50 Pharmacy Benefit Management Market in US by Insurance Companies and Retail Pharmacies 2019–2025 ($ billion)
Exhibit 51 Pharmacy Benefit Management Market in US by Pure Play PBMs 2019–2025 ($ billion)
List of Tables
Table 1 Key Caveats
Table 2 Currency Conversion 2013−2019
Table 3 Medical Vs. Pharmacy Benefit
Table 4 Vertical Integration among Significant Companies
Table 5 Market Ranking Analysis 2019
Table 6 CVS Caremark: Service Offerings
Table 7 Express Scripts: Service Offerings
Table 8 OptumRx: Service Offerings
Table 9 Humana Pharmacy Solutions: Service Offerings
Table 10 Abarca Health Solutions: Service Offerings
Table 11 Anthem: Service Offerings
Table 12 Ascella Health: Service Offerings
Table 13 BeneCard PBF: Service Offerings
Table 14 Centene: Service Offerings
Table 15 Citizens Rx: Service Offerings
Table 16 EnvisionRxOptions: Service Offerings
Table 17 Excelera: Service Offerings
Table 18 Magellan Rx Management: Service Offerings
Table 19 MedalistRx: Service Offerings
Table 20 MedImpact Healthcare Systems: Service Offerings
Table 21 Prime Therapeutics: Service Offerings
Table 22 MaxorPlus: Service Offerings
Table 23 Navitus Health Solutions: Service Offerings
Table 24 Perform Rx: Service Offerings
Table 25 RxAdvance: Service Offerings
Table 26 WellDyne RX: Service Offerings
Table 27 Pharmacy Benefit Management Market in US by Service ($ billion)
Table 28 Pharmacy Benefit Management Market in US by Service (%)
Table 29 Pharmacy Benefit Management Market in US by Health Plan ($ billion)
Table 30 Pharmacy Benefit Management Market in US by Health Plan (%)
Table 31 Pharmacy Benefit Management Market in US by Business Model ($ billion)
Table 32 Pharmacy Benefit Management Market in US by Business Model (%)

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