Who are the Big 3 PBMs? A Comprehensive Guide
When it comes to pharmacy benefit management (PBM), the “big three” are Caremark (CVS Health), Express Scripts (Cigna), and OptumRx (United Health Group). These three PBMs are the largest and most influential in the industry, and they have a significant impact on the cost and availability of prescription drugs. In this guide, we’ll explain who the big three PBMs are, how they operate, and what their impact is on the cost and availability of prescription drugs.
What is a PBM?
A pharmacy benefit manager (PBM) is a third-party administrator of prescription drug programs. PBMs are responsible for managing the formulary, processing and paying prescription drug claims, and negotiating discounts and rebates with drug manufacturers. PBMs also provide services such as drug utilization review, drug therapy management, and disease management.
Who are the Big 3 PBMs?
The three largest PBMs in the United States are Caremark (CVS Health), Express Scripts (Cigna), and OptumRx (United Health Group). Together, these three PBMs manage the prescription drug benefits of more than 200 million Americans. They are responsible for negotiating discounts and rebates with drug manufacturers, processing and paying prescription drug claims, and managing the formulary (the list of drugs covered by a health plan).
How do the Big 3 PBMs Operate?
The big three PBMs operate in a variety of ways. They negotiate discounts and rebates with drug manufacturers, process and pay prescription drug claims, and manage the formulary. They also provide services such as drug utilization review, drug therapy management, and disease management. In addition, they provide data and analytics to help health plans and employers make informed decisions about their prescription drug benefits.
What is the Impact of the Big 3 PBMs?
The big three PBMs have a significant impact on the cost and availability of prescription drugs. They negotiate discounts and rebates with drug manufacturers, which can result in lower prices for consumers. They also manage the formulary, which can affect which drugs are covered by a health plan. In addition, they provide data and analytics that can help health plans and employers make informed decisions about their prescription drug benefits.
“The Big 3 PBMs have a tremendous amount of power in the marketplace, and their decisions can have a significant impact on the cost and availability of prescription drugs.”
– Dr. Mark Fendrick, Director of the Center for Value-Based Insurance Design
For example, for 2023, the three largest PBMs—Caremark (CVS Health), Express Scripts (Cigna), and OptumRx (United Health Group)—have again increased the number of drugs they exclude from their standard formularies. This means that some drugs may no longer be covered by a health plan, or may only be covered at a higher cost. As a result, it is important for consumers to be aware of the formulary changes and to understand how they may affect their prescription drug costs.
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What is a Formulary?
A formulary is a list of drugs covered by a health plan. It is managed by a PBM and can include both generic and brand-name drugs. The formulary is used to determine which drugs are covered by a health plan and at what cost. It is important for consumers to be aware of the formulary changes and to understand how they may affect their prescription drug costs.
What is Drug Utilization Review?
Drug utilization review (DUR) is a process used by PBMs to ensure that prescription drugs are being used safely and appropriately. DUR involves reviewing a patient’s medication history to identify potential drug-related problems, such as drug interactions, incorrect dosages, or duplicate therapies. DUR can help reduce the risk of adverse drug events and improve patient safety.
What is Drug Therapy Management?
Drug therapy management (DTM) is a process used by PBMs to optimize the use of medications. DTM involves assessing a patient’s medication regimen to identify potential problems, such as drug interactions, incorrect dosages, or duplicate therapies. DTM can help reduce the risk of adverse drug events and improve patient safety.
Conclusion
The big three PBMs—Caremark (CVS Health), Express Scripts (Cigna), and OptumRx (United Health Group)—are the largest and most influential PBMs in the United States. They are responsible for negotiating discounts and rebates with drug manufacturers, processing and paying prescription drug claims, and managing the formulary. They also provide services such as drug utilization review, drug therapy management, and disease management. Their decisions can have a significant impact on the cost and availability of prescription drugs, so it is important for consumers to be aware of the formulary changes and to understand how they may affect their prescription drug costs.
This guide has provided an overview of who the big three PBMs are, how they operate, and what their impact is on the cost and availability of prescription drugs. For more information, please refer to the following sources:
- Medicaid.gov: Pharmacy Benefit Managers
- Centers for Medicare & Medicaid Services: Prescription Drug Coverage & Contraceptive Coverage
- National Center for Biotechnology Information: Pharmacy Benefit Managers: An Overview of Their Role in the US Healthcare System
The big three PBMs have a significant impact on the cost and availability of prescription drugs, so it is important for consumers to be aware of their formulary changes and to understand how they may affect their prescription drug costs.