Three pharmacy benefit managers accounted for nearly 80% of prescription claims processed last year, according to a report released by Drug Channels Institute (DCI) Tuesday morning.
CVS Health’s Caremark, Cigna’s Evernoth/Express Scripts and UnitedHealth’s OptumRx dominated as the top PBMs of 2022, the report found. The remaining 20% is accounted for by Humana Pharmacy Solutions, Prime Therapeutics/Magellan Rx, MedImpact Healthcare Systems as well as all other PBMs and cash pay.
The report noted the vertical integrations that have taken place over the past half-decade, with five of the six largest PBMs being owned by an organization that also owns a health insurer.
While the top three PBMs’ aggregate share of claims was similar to the figures from 2021, the study indicated that Cigna’s share declined due to customer losses while OptumRx’s share grew slightly.
Looking ahead, DCI stated that Express Scripts will begin a five-year contract next year to manage the pharmacy benefits for more than 20 million Centene beneficiaries, which is expected to bring in more than 550 million prescriptions as well as $35 to $40 billion in total gross pharmacy spend.
The market estimates come as PBMs face heightened scrutiny over their business model, with Congress eyeing action to rein in high prescription drug prices.
Earlier this month, PBM executives testified during a hearing held by the Senate Health, Education, Labor and Pensions (HELP) Committee about the price of insulin and their role in the drug prices faced by patients nationwide.
Express Scripts president Adam Kautzner, OptumRx CEO Heather Cianfrocco and David Joyner, EVP and president of pharmacy services at CVS Health, testified at the panel led by Sen. Bernie Sanders, (I-Vt.).
Arguably the most compelling moment of the hearing came when Sen. Markwayne Mullin, (R-Ok.), claimed PBMs were essentially rebating themselves since they are owned by large health insurers and suggested shutting them down due to their ineffectiveness.
However, the PBM executives held the line and countered the suggestion that drug rebates are increasing list prices and costs for patients.
In a commentary accompanying the market estimates, DCI CEO Adam J. Fein, PhD, wrote that despite the ever-growing political rhetoric around how to address PBMs, large plan sponsor clients of the top three PBMs are “not advocating for massive change” in their PBM relationships.
“They have also not been demanding that Congress protect them from their PBM vendors. Employers seem reluctant to disrupt systems that mostly work, even if those systems are partially uneconomic or somewhat inefficient,” Fein wrote.