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

  • ID: 5067351
  • Report
  • June 2020
  • Region: United States
  • 200 pages
  • Arizton
until Aug 15th 2021


  • Abarca Health
  • BeneCard PBF
  • CVS Caremark
  • Express Scripts
  • MaxorPlus
  • Navitus Health Solutions
  • MORE
1h Free Analyst Time

Speak directly to the analyst to clarify any post sales queries you may have.

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.


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

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
Other 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
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.?
Note: Product cover images may vary from those shown


  • Abarca Health
  • BeneCard PBF
  • CVS Caremark
  • Express Scripts
  • MaxorPlus
  • Navitus Health Solutions
  • MORE
1 Research Methodology

2 Research Objectives

3 Research Process

4 Scope & Coverage
4.1 Market Definition
4.2 Base Year
4.3 Scope Of The Study
4.4 Market Segments

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

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

12 Service
12.1 Market Snapshot & Growth Engine
12.2 Market Overview
12.3 Specialty Pharmacy Services
12.4 Retail Pharmacy Services
12.5 Mail-order Pharmacy Services
12.6 Benefit Plan Design and Administration
12.7 Formulary Management
12.8 Clinical Programs and Services
12.9 Others

13 Health Plan
13.1 Market Snapshot & Growth Engine
13.2 Market Overview
13.3 Commercial Health Plans
13.4 Medicare Part D Plans
13.5 Self-insured Health Plans
13.6 Managed Medicaid Programs
13.7 Others

14 Business Model
14.1 Market Snapshot & Growth Engine
14.2 Market Overview
14.3 Insurance Companies and Retail Pharmacies
14.4 Pure Play PBMs

15 Competitive Landscape
15.1 Competitive Scenario

16 Market Vendor Analysis
16.1 Market Ranking Analysis

17 Key Company Profiles
17.1 CVS Caremark
17.4 Humana Pharmacy Solutions

18 Other Prominent Vendors
18.1 Abarca Health
18.2 Anthem
18.3 Ascella Health
18.4 BeneCard PBF
18.5 Centene
18.6 Citizens Rx
18.7 EnvisionRxOptions
18.8 Excelera
18.9 Magellan Rx Management
18.10 MedalistRx
18.11 MedImpact Healthcare Systems
18.12 Prime Therapeutics
18.13 MaxorPlus
18.14 Navitus Health Solutions
18.15 Perform Rx
18.16 RxAdvance
18.17 WellDyne RX

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
Note: Product cover images may vary from those shown
  • CVS Caremark
  • Express Scripts
  • OptumRx
  • Humana Pharmacy Solutions
  • 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
Note: Product cover images may vary from those shown

Our research comprises a mix of primary and secondary research. The secondary research sources that are typically referred to include, but are not limited to, company websites, annual reports, financial reports, company pipeline charts, broker reports, investor presentations and SEC filings, journals and conferences, internal proprietary databases, news articles, press releases, and webcasts specific to the companies operating in any given market.

Primary research involves email interactions with the industry participants across major geographies. The participants who typically take part in such a process include, but are not limited to, CEOs, VPs, business development managers, market intelligence managers, and national sales managers. We primarily rely on internal research work and internal databases that we have populated over the years. We cross-verify our secondary research findings with the primary respondents participating in the study.