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Pharmacy Benefit Managers

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The cost of prescription drugs in the United States is a subject about which there is much controversy. As the Affordable Care Act—or, Obamacare—gets off to a rocky start across the nation, we decided to look at just one small part of the prescription drug distribution network, about which most people are not particularly conscious. That is the segment made up of Pharmacy Benefit Managers (PBMs), middlemen who stand in a central position in the the prescription drug supply chain and who, it turns out, have carved out for themselves a rather lucrative business. The three largest PBMs—Express Scripts, CVS Caremark, and OptumRx—together control about 70% of all prescriptions filled in the United States.

PBMs are firms that provide an administrative service to insurance companies, large self-insured employers, and government benefit providers. They develop and maintain drug formularies—lists of specific drugs to be covered and the prices for each—for their insurance providing customers. They also negotiate with pharmaceutical companies for preferred pricing on the drugs covered in those formularies and they negotiate with retailers to accept those terms and participate in the PBM’s network of preferred pharmacies.

According to an article in Fortune magazine, “PBMs started as paper pushers: They began hand-processing medical claims in the 1970s and evolved into middlemen who touted their ability to use corporate customers’ combined purchasing power to negotiate huge discounts from pharmaceutical companies. Today the top PBMs are as big as or bigger than their clients.” The United States has a most unique health care delivery system, one which is significantly fuller of lucrative middleman-businesses than the systems present in other industrialized nations.

Today’s market size is the total estimated revenue earned by Pharmacy Benefit Managers in the United States in 2012.

Geographic reference: United States
Year: 2012
Market size: $250 billion
Source: Katherine Eban, “Painful Prescription,” Fortune, October 28, 2013, pages 202-207.
Original Source: J.P. Morgan analysts
Posted on November 4, 2013


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