U.S. Pharmacy Benefit Management Market Size, Share, and Trends 2024 to 2033

U.S. Pharmacy Benefit Management Market Forecast

The U.S. pharmacy benefit management market size was USD 382.19 billion in 2023, accounted for USD 419.14 billion in 2024, and is expected to reach around USD 961.39 billion by 2033, expanding at a CAGR of 9.7% from 2024 to 2033.

U.S. Pharmacy Benefit Management Market Key Takeaways

• By Business Model, the standalone PBM segment dominated the market with the largest market share of 60% in 2023.
• By Business Model, the healthcare insurance provider segment is expected to generate significant revenue throughout the forecast period.
• By Services, the specialty pharmacies segment dominated the market in 2023.
• By Services, the retail services segment is expected to witness significant growth during the predicted timeframe.
• By End-user, the commercial segment projected the highest market growth in 2023.
• By End-user, the federal segment is expected to dominate the market during the anticipated time period.

Market Overview

Pharmacy benefits management is generally defined as it is a group of companies that provide middlemen in pharmacies and insurance companies and drug manufacturing. Pharmacy benefits management plays a major role in securing and deciding the cost of the drug for insurance and insurance companies. These services decide the cost of drugs by negotiating with pharmaceutical companies and pharmacies. These discounts are then passed to the insurance companies.

The pharmacy benefits management market in the United States offer multiple services, plans as well as business models. The market services in the nation include health plans, health services and specialty services such as claim processing, retail pharmacy networks, formulary management, disease management, adherence initiatives and drug utilization reviews.

U.S. Pharmacy Benefit Management Market Growth Factors

The healthcare industry is the widest and most ever-expanding industry. Healthcare infrastructure is rising enormously in the United States. Drugs and treatment cost is the major hurdle that arises for the patients. Pharmacy benefits management works on the management of the cost of the drugs. While the economically well-established countries including the United States have allocated a big budget for healthcare infrastructure facilities, the adoption rate of such services to manage the overall budget of the industry is high. Due to the rising drug cost, there is not a surprise that pharmacy benefits management services are expanding in the United States. Moreover, the development of novel drugs in the market of United States will continue to highlight the acceleration of the market in the upcoming years.

The Pharmacy benefits management companies work on negotiating the cost of the drug by ensuring the bulk purchases and payments. The benefits can be helpful for consumers. By lowering the cost of the drugs and treatment, the PBM organizers aim to help to ensure the appropriate drug usage and maintain drug safety. Thus, this benefit offered by the services will continue to act as a growth factor for the market.

U.S. Pharmacy Benefit Management Market Scope

U.S. Pharmacy Benefit Management Market Dynamics

Driver:

Increasing medication accessibility

Access to medical services in the United States is facilitated by making sure that the medications are both affordable and safe. Patients who receive individualized care may also feel secure enough to take their prescribed drugs without being concerned about the expense or course of their care. In keeping with a tailored strategy, PBMs can work with companies to offer insightful counsel on efficient health plans. The objective of this activity is to deliver the greatest care at the most affordable cost. These groups can also seek approaches to increase the availability of specialist medications for individuals who require them.

The increasing accessibility to medication can drive the growth of the market by expanding the customer base and increasing the volume of prescriptions processes. This could lead to greater demand for PBM services as more individuals gain access to healthcare and pharmaceuticals. Additionally, a larger patient population could lead to increased negotiations with drug manufacturers for better pricing, which PBMs facilitate, further contributing to the market’s growth.

Restraint:

Lack of transparency

Due to the difficulties with pharmaceutical benefit managers, there is a discussion on the transparency of PBM activities. PBMs assert that they are in a good position to save plans and customers money, but because their business practices are opaque, they are frequently able to utilize their clout to increase their profits at the expense of the customer. This has prompted policymakers to consider changing the rebate system by requiring PBMs to pass along more rebate savings or increasing transparency. The lack of transparency in the market acts as a restraint by making it difficult for stakeholders, such as patients, employers and even for healthcare providers. This lack of visibility into pricing mechanisms and negotiations between PBMs and pharmaceutical manufacturers can hinder competition and potentially lead to higher healthcare costs for consumers.

Opportunity:

Integration of digital treatment program

The expanded use of evidence-based digital treatment programs to treat chronic illnesses is one area of digital health that, driven by customer demand. It is essential to change behavior in order to enhance employee health outcomes and to offer tried-and-true software, applications, and other digital technologies to assist people in managing and treating a wide range of illnesses. Offering digital treatment programs that are supported by clinical research and recognized by regulatory agencies can result in fewer complications or hospitalizations as well as lower healthcare expenditures for both the employee and the plan sponsor.

The integration of digital treatment programs in the United States pharmacy benefit management market is observed to present multiple opportunities as it offers several benefits such as personalized patient care, better medication adherence and better management of chronic conditions. These programs can enhance patient engagement, monitor medication usage and offer real-time data to healthcare providers, leading to more effective and efficient treatment outcomes. As a result, PBMs can leverage these digital solutions to optimize medication management, control costs and enhance patient well-being, thereby influencing the growth of the market.

Business Model Insights

The standalone PBM segment dominated the market with the highest market share in 2023. The dominance of the segment is attributed to the presence of the major free-standing pharmaceutical companies. The business model segment’s growth is also driven by the specialized focus and adaptability of standalone PMBs. These PBMs operate independently, allowing them to tailor their services to meet the unique needs of clients, such as insurance companies and government programs.

Moreover, their independence fosters transparency in pricing and contracting, fostering trust among stakeholders. Clients appreciate transparency, as it aligns with their goals of reducing costs and enhancing patient outcomes. The focused expertise of standalone PBMs allows for efficient drug formulary management, claims processing and medication counseling.

The health insurance provider segment is expected to grow at a significant rate during the forecast period. The growth of the segment is attributed to the increasing number of populations insured under commercial insurance and rising access to public health insurance. With the rising number of assigned insurances, several payers are assigned to the PBM which is also one of the driving factors for the segment.

Service Insights:

The specialty pharmacies segment dominated the market with the highest market share in 2023.  Specialty pharmacies are special kinds of medication which is helpful for patients with chronic diseases and more severe illnesses, the rising cases of chronic diseases in the nations supplement to the segment’s growth. Specialty pharmacies deal with patients and pharmacies for providing medication for chronic illnesses. Specialty pharmacies provide treatment for patients with more detailed education. Specialty medication requires patient monitoring and management. There is an additional staff that works in the specialty pharmacies which will ensure education adherence and increase the effectiveness of the treatment plan. Specialty pharmacy staff communicate with patients up to date about adjustment and changes which are required for the treatment plan.

The retail pharmacies segment is expected to grow in the market during the forecast period. Retail pharmacy is the most common type of practice for Americans to visit for medication. Retail pharmacies are generally used for the common type of treatment and work on several prescriptions. Retail pharmacies offer medication for treatment like allergies, high blood pressure, cold and flu remedies, antibiotics, etc. The chances of adoption of pharmacy benefit management services by retail pharmacies are high owing to the availability of large number of consumers.

End-User Insights:

The commercial segment dominated the market in 2023. With employers-sponsored health insurance being the prevalent mode of coverage, a large portion of the population falls under the commercial category. This translates to a substantial number of individuals seeking prescription medications through commercial health plans. The commercial segment’s dominance is expected to extend due to its influence in shaping PBM contracts and service offerings. These entities often demand tailored solutions to meet the needs of their diverse employee populations.

U.S. Pharmacy Benefit Management Market Companies

• CVS Health
• Cigna
• Optum, Inc.
• MedImpact
• Anthem
• Change Healthcare
• Prime Therapeutics LLC
• HUB International Limited.
• Elixir Rx Solutions LLC

Recent Developments

• In Aug 2023, Maria Cantwell and BUTLER COUNTY, Chuck Grassley (R-Iowa) announced the major nonprofit advocacy group “AARP” which is advertised by Pharmacy Benefit Manager (PBM) Transparency Act.
• In Aug 2023, the pharmacy-benefit manager of CVS Caremark dropped by Blue Shield of California in approval of a company’s group that will provide the services at the same cost. The drug-pricing contracts of pharmacy-benefit manager Prime Therapeutics used by the Blue Shield.

Segment Covered in the Report:

By Business Model

• Standalone PBM
• Health Insurance Providers

By Service

• Specialty Pharmacy
• Retail Pharmacy

By End-user

• Commercial
• Federal