Pharmacy Benefit Management Market in the US - Industry Outlook & Forecast 2022-2027
The study considers a detailed scenario of the present U.S. pharmacy benefit management market and its market dynamics for 2022−2027. It covers a detailed overview of several industry growth enablers, restraints, and trends. The report offers both the demand and supply aspects of the market. It profiles and examines leading companies and other prominent ones operating in the market.
The U.S. pharmacy benefit management market is expected to grow at a CAGR of 5.53% during 2022-2027
MARKET INSIGHTS
The PBM industry refers to companies that act as intermediaries between insurance companies, pharmacies, and pharmaceutical companies. PBM is responsible for reducing insurers and their drug costs. They achieve this by negotiating with pharmacies and pharmaceutical companies. The pharmacy benefit management systems entered the pharmaceutical industry in the 1960s to meet the needs of employer-based health benefits. They soon became an important stakeholder in the entire pharmaceutical supply chain.
Pharmacy costs represent almost 32% of the total health care spending, and this expenditure is expected to grow more than two times during the forecast period. Currently, pharmacy benefit management plays a major role and acts as an intermediary between payers, drug manufacturers, and pharmacies.
Since PBMs play a significant role in influencing out-of-pocket costs and patient access to medications owing to their management tools, formulary power, and price concessions. They are in a position of power to pass savings to customers. According to PBM lobby groups, between 2020 to 2029, PBM tools will reduce consumer and plan sponsors' spending by more than $1 trillion.
There is a growing criticism of PBMs with claims that they are driving up costs of drug prices, making huge gains via pharmacy spreads, rebates from manufacturers, and fees from the supply chain. This is being spurred by the opaqueness of the true cost of drugs to PBMs owing to the rules of engagement between manufacturers and PBMs.
The future of PBMs is going to be dictated by the implementation of state and national-level policies in terms of their revenue streams and business practices in the pharmaceutical space.
U.S. Pharmacy Benefit Management Market Segmentations
- Based on services, specialty pharmacy services are the major contributor in the pharmacy benefit management market in the US, and it is likely to witness high incremental growth of $48.24 billion during the forecast period.
- Based on health plans, commercial health plans are the major contributor in the pharmacy benefit management market in the US, and it is likely to witness high absolute growth of 34.69% during the forecast period.
Segmentation by Health Plan
- Commercial Health Plans
- Medicare
- Medicaid
- Others
Segmentation by Services
- Specialty Pharmacy Services
- Retail Pharmacy Networks
- Mail-Order Pharmacy Services
- Claims Processing
- Formulary Management
- Drug Utilization Review
- Price, Discount, & Rebate Negotiations
- Disease Management & Adherence Initiatives
Segmentation by Business Model
- Insurance Companies and Retail Pharmacies
- Pure Play PBMS
VENDOR ANALYSIS
The presence of prominent market players, increasing favorable healthcare reforms, rising e-prescription, and growing adoption of healthcare plans by us residents are the primary factors for the significant market share in the country.
Key Company Profiles
- CVS Health
- Cigna
- UnitedHealth Group
Key Companies to Watch
- Humana Pharmacy Solutions
- Medimpact
- Prime Therapeutics
Other Prominent Vendors
- Abarca Health
- AscellaHealth
- BeneCard PBF
- CaptureRx
- Centene
- Change Healthcare
- Citizens Rx
- EnvisionRxOptions
- Excelera
- Magellan Rx Management
- MedalistRx
- MaxorPlus
- Navitus Health Solutions
- PerformRx
- ProCare Rx
- RxAdvance
- Rite Aid
- WellDyneRx
- Walgreens Boots Alliance
- 1 RESEARCH METHODOLOGY
- 2 RESEARCH OBJECTIVES
- 3 RESEARCH PROCESS
- 4 SCOPE & COVERAGE
- 4.1 MARKET DEFINITION
- 4.1.1 INCLUSIONS
- 4.1.2 EXCLUSIONS
- 4.1.3 MARKET ESTIMATION CAVEATS
- 4.2 BASE YEAR
- 4.3 SCOPE OF THE STUDY
- 4.4 MARKET SEGMENTATION
- 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 US ECONOMY & HEALTHCARE INDUSTRY LANDSCAPE
- 7.2 PHARMACY BENEFIT MANAGEMENT
- 7.2.1 ROLE OF PBMS IN MONEY SPENT ON PRESCRIPTION DRUGS
- 7.2.2 REFORMS TO REGULATE PBMS
- 8 PHARMACEUTICAL ECOSYSTEM
- 8.1 OVERVIEW
- 8.2 EVOLUTION OF PBM OWNERSHIP
- 8.2.1 PBM SERVICES OVER TIME
- 8.2.2 PBMS & OTHER PLAYERS IN PHARMACEUTICAL ECOSYSTEM
- 9 IMPACT OF COVID-19 ON PBM MARKET
- 9.1 OVERVIEW
- 9.1.1 PBMS COVID-19 RESPONSE STRATEGIES
- 10 GAPS IN INFORMATION & CARE IN US HEALTHCARE INDUSTRY
- 10.1 OVERVIEW
- 11 MARKET OPPORTUNITIES & TRENDS
- 11.1 INCREASED ADOPTION OF E-PRESCRIPTION & MAIL ORDER PHARMACY
- 11.2 GROWING FDA APPROVALS OF BIOLOGICS & BIOSIMILARS
- 11.3 MARKET ENTRY OF PAYERS THROUGH M&AS
- 11.4 ENTRY OF DIGITAL HEALTH SOLUTIONS IN PBM INDUSTRY
- 12 MARKET GROWTH ENABLERS
- 12.1 FAVORABLE HEALTHCARE REFORMS
- 12.2 GROWING ADOPTION OF HEALTHCARE PLANS BY US RESIDENTS
- 12.3 PREVALENCE OF FRAUD, WASTE & ABUSE IN HEALTHCARE
- 12.4 INCREASED DEMAND FOR PERSONALIZED MEDICINES
- 13 MARKET RESTRAINTS
- 13.1 PBMS MORE SUSCEPTIBLE TO LAWSUITS & GOVERNMENT SCRUTINY
- 13.2 LACK OF TRANSPARENCY IN SERVICES BY PBMS
- 13.3 DECLINING GROWTH FROM GENERICS
- 13.4 LEGAL UNCERTAINTY & IMPENDING LIMITATIONS ON PBM TOOLS
- 14 MARKET LANDSCAPE
- 14.1 MARKET OVERVIEW
- 14.2 MARKET SIZE & FORECAST
- 14.2.1 INSIGHT BY HEALTH PLANS
- 14.2.2 INSIGHTS BY SERVICES
- 14.2.3 INSIGHT BY BUSINESS MODEL
- 14.3 FIVE FORCES ANALYSIS
- 14.3.1 THREAT OF NEW ENTRANTS
- 14.3.2 BARGAINING POWER OF SUPPLIERS
- 14.3.3 BARGAINING POWER OF BUYERS
- 14.3.4 THREAT OF SUBSTITUTES
- 14.3.5 COMPETITIVE RIVALRY
- 15 HEALTH PLANS
- 15.1 MARKET SNAPSHOT & GROWTH ENGINE
- 15.2 MARKET OVERVIEW
- 15.3 COMMERCIAL HEALTH PLANS
- 15.3.1 MARKET OVERVIEW
- 15.3.2 MARKET SIZE & FORECAST
- 15.4 MEDICARE
- 15.4.1 MARKET OVERVIEW
- 15.4.2 MARKET SIZE & FORECAST
- 15.5 MEDICAID
- 15.5.1 MARKET OVERVIEW
- 15.5.2 MARKET SIZE & FORECAST
- 15.6 OTHERS
- 15.6.1 MARKET OVERVIEW
- 15.6.2 MARKET SIZE & FORECAST
- 16 SERVICES
- 16.1 MARKET SNAPSHOT & GROWTH ENGINE
- 16.2 MARKET OVERVIEW
- 16.3 SPECIALTY PHARMACY SERVICES
- 16.3.1 MARKET OVERVIEW
- 16.3.2 MARKET SIZE & FORECAST
- 16.4 RETAIL PHARMACY NETWORKS
- 16.4.1 MARKET OVERVIEW
- 16.4.2 MARKET SIZE & FORECAST
- 16.5 MAIL-ORDER PHARMACY SERVICES
- 16.5.1 MARKET OVERVIEW
- 16.5.2 MARKET SIZE & FORECAST
- 16.6 CLAIMS PROCESSING
- 16.6.1 MARKET OVERVIEW
- 16.6.2 MARKET SIZE & FORECAST
- 16.7 FORMULARY MANAGEMENT
- 16.7.1 MARKET OVERVIEW
- 16.7.2 MARKET SIZE & FORECAST
- 16.8 DRUG UTILIZATION REVIEW
- 16.8.1 MARKET OVERVIEW
- 16.8.2 MARKET SIZE & FORECAST
- 16.9 PRICE, DISCOUNT & REBATE NEGOTIATIONS
- 16.9.1 MARKET OVERVIEW
- 16.9.2 MARKET SIZE & FORECAST
- 16.10 DISEASE MANAGEMENT & ADHERENCE INITIATIVES
- 16.10.1 MARKET OVERVIEW
- 16.10.2 MARKET SIZE & FORECAST
- 17 BUSINESS MODEL
- 17.1 MARKET SNAPSHOT & GROWTH ENGINE
- 17.2 MARKET OVERVIEW
- 17.3 INSURANCE COMPANIES & RETAIL PHARMACIES
- 17.3.1 MARKET OVERVIEW
- 17.3.2 MARKET SIZE & FORECAST
- 17.4 PURE PLAY PBMS
- 17.4.1 MARKET OVERVIEW
- 17.4.2 MARKET SIZE & FORECAST
- 18 COMPETITIVE LANDSCAPE
- 18.1 COMPETITION OVERVIEW
- 18.2 MARKET SHARE ANALYSIS
- 18.2.1 CVS HEALTH
- 18.2.2 CIGNA
- 18.2.3 UNITEDHEALTH GROUP
- 18.2.4 HUMANA PHARMACY SOLUTIONS
- 18.2.5 MEDIMPACT
- 18.2.6 PRIME THERAPEUTICS
- 19 KEY COMPANY PROFILES
- 19.1 CVS HEALTH
- 19.1.1 BUSINESS OVERVIEW
- 19.1.2 SERVICE OFFERINGS
- 19.1.3 KEY STRENGTHS
- 19.1.4 KEY STRATEGIES
- 19.1.5 KEY OPPORTUNITY
- 19.2 CIGNA
- 19.2.1 BUSINESS OVERVIEW
- 19.2.2 SERVICE OFFERINGS
- 19.2.3 KEY STRENGTHS
- 19.2.4 KEY STRATEGIES
- 19.2.5 KEY OPPORTUNITY
- 19.3 UNITEDHEALTH GROUP
- 19.3.1 BUSINESS OVERVIEW
- 19.3.2 SERVICE OFFERINGS
- 19.3.3 KEY STRENGTH
- 19.3.4 KEY STRATEGIES
- 19.3.5 KEY OPPORTUNITY
- 20 KEY COMPANIES TO WATCH
- 20.1 HUMANA PHARMACY SOLUTIONS
- 20.1.1 BUSINESS OVERVIEW
- 20.1.2 SERVICE OFFERINGS
- 20.1.3 KEY STRENGTHS
- 20.1.4 KEY STRATEGIES
- 20.1.5 KEY OPPORTUNITY
- 20.2 MEDIMPACT
- 20.2.1 BUSINESS OVERVIEW
- 20.2.2 SERVICE OFFERINGS
- 20.2.3 KEY STRENGTHS
- 20.2.4 KEY STRATEGIES
- 20.2.5 KEY OPPORTUNITIES
- 20.3 PRIME THERAPEUTICS
- 20.3.1 BUSINESS OVERVIEW
- 20.3.2 SERVICE OFFERINGS
- 20.3.3 KEY STRENGTHS
- 20.3.4 KEY STRATEGIES
- 21 OTHER PROMINENT VENDORS
- 21.1 ABARCA HEALTH
- 21.1.1 BUSINESS OVERVIEW
- 21.1.2 SERVICE OFFERINGS
- 21.1.3 KEY STRENGTHS
- 21.1.4 KEY STRATEGIES
- 21.2 ANTHEM
- 21.2.1 BUSINESS OVERVIEW
- 21.2.2 SERVICE OFFERINGS
- 21.2.3 KEY STRATEGIES
- 21.2.4 KEY STRENGTHS
- 21.3 ASCELLAHEALTH
- 21.3.1 BUSINESS OVERVIEW
- 21.3.2 SERVICE OFFERINGS
- 21.3.3 KEY STRENGTHS
- 21.3.4 KEY STRATEGIES
- 21.4 BENECARD PBF
- 21.4.1 BUSINESS OVERVIEW
- 21.4.2 SERVICE OFFERINGS
- 21.4.3 KEY STRENGTHS
- 21.4.4 KEY STRATEGIES
- 21.5 CAPTURERX
- 21.5.1 BUSINESS OVERVIEW
- 21.5.2 SERVICE OFFERINGS
- 21.5.3 KEY STRENGTHS
- 21.5.4 KEY STRATEGIES
- 21.6 CENTENE
- 21.6.1 BUSINESS OVERVIEW
- 21.6.2 SERVICE OFFERINGS
- 21.6.3 KEY STRENGTHS
- 21.6.4 KEY STRATEGIES
- 21.7 CHANGE HEALTHCARE
- 21.7.1 BUSINESS OVERVIEW
- 21.7.2 SERVICE OFFERINGS
- 21.7.3 KEY STRENGTHS
- 21.7.4 KEY STRATEGIES
- 21.8 CITIZENS RX
- 21.8.1 BUSINESS OVERVIEW
- 21.8.2 SERVICE OFFERINGS
- 21.8.3 KEY STRENGTHS
- 21.8.4 KEY STRATEGIES
- 21.9 ENVISIONRXOPTIONS
- 21.9.1 BUSINESS OVERVIEW
- 21.9.2 SERVICE OFFERINGS
- 21.9.3 KEY STRENGTHS
- 21.9.4 KEY STRATEGIES
- 21.10 EXCELERA
- 21.10.1 BUSINESS OVERVIEW
- 21.10.2 SERVICE OFFERINGS
- 21.10.3 KEY STRENGTHS
- 21.10.4 KEY STRATEGIES
- 21.11 MAGELLAN RX MANAGEMENT
- 21.11.1 BUSINESS OVERVIEW
- 21.11.2 SERVICE OFFERINGS
- 21.11.3 KEY STRENGTHS
- 21.11.4 KEY STRATEGIES
- 21.12 MEDALISTRX
- 21.12.1 BUSINESS OVERVIEW
- 21.12.2 SERVICE OFFERINGS
- 21.12.3 KEY STRENGTH
- 21.12.4 KEY STRATEGIES
- 21.13 MAXORPLUS
- 21.13.1 BUSINESS OVERVIEW
- 21.13.2 SERVICE OFFERINGS
- 21.13.3 KEY STRENGTHS
- 21.13.4 KEY STRATEGIES
- 21.14 NAVITUS HEALTH SOLUTIONS
- 21.14.1 BUSINESS OVERVIEW
- 21.14.2 SERVICE OFFERINGS
- 21.14.3 KEY STRENGTH
- 21.14.4 KEY STRATEGY
- 21.15 PERFORMRX
- 21.15.1 BUSINESS OVERVIEW
- 21.15.2 SERVICE OFFERINGS
- 21.15.3 KEY STRENGTHS
- 21.15.4 KEY STRATEGIES
- 21.16 PROCARE RX
- 21.16.1 BUSINESS OVERVIEW
- 21.16.2 SERVICE OFFERINGS
- 21.16.3 KEY STRENGTHS
- 21.16.4 KEY STRATEGIES
- 21.17 RXADVANCE
- 21.17.1 BUSINESS OVERVIEW
- 21.17.2 SERVICE OFFERINGS
- 21.17.3 KEY STRENGTHS
- 21.17.4 KEY STRATEGIES
- 21.18 RITE AID
- 21.18.1 BUSINESS OVERVIEW
- 21.18.2 SERVICE OFFERINGS
- 21.18.3 KEY STRENGTHS
- 21.18.4 KEY STRATEGIES
- 21.19 WELLDYNERX
- 21.19.1 BUSINESS OVERVIEW
- 21.19.2 SERVICE OFFERINGS
- 21.19.3 KEY STRENGTHS
- 21.19.4 KEY STRATEGIES
- 21.20 WALGREENS BOOTS ALLIANCE
- 21.20.1 BUSINESS OVERVIEW
- 21.20.2 SERVICE OFFERINGS
- 21.20.3 KEY STRENGTHS
- 21.20.4 KEY STRATEGIES
- 22 REPORT SUMMARY
- 22.1 KEY TAKEAWAYS
- 22.2 STRATEGIC RECOMMENDATIONS
- 23 QUANTITATIVE SUMMARY
- 23.1 MARKET BY HEALTH PLANS
- 23.2 MARKET BY SERVICES
- 23.3 MARKET BY BUSINESS MODEL
- 24 APPENDIX
- 24.1 ABBREVIATIONS