The analysis, based on 2022 and 2023 prescription drug plan (PDP) enrollee information, found low PBM market competition and high vertical integration as the largest PBMs share ownership with health insurers. Among the key findings:

OptumRx was the largest PBM in the United States in 2023, with a 22.2% market share, up slightly from 20.8% in 2022. CVS Health followed with an 18.9% share, down from 21.3% in 2022. Express Scripts was third largest, with a 15.5% share, followed by Prime Therapeutics, with a 10.6% share.
Seventy-nine percent of PDP region-level PBM markets lacked adequate competition and were "highly concentrated," according to 2023 federal antitrust guidelines.
Nationally, 77% of commercial and Part D enrollees were in a PDP where the insurer and PBM were vertically integrated. The vertically integrated share was higher in Part D than in commercial insurance (88% vs. 71%).
At the regional level, an average of 76% of enrollees were in a PDP where the insurer and PBM were vertically integrated.
There was wide variation across PDP regions, with some having little vertical integration between insurers and PBMs, while others were almost entirely vertically integrated.
Nine of the 10 largest PBMs share ownership with health insurers.

Instant Insights /

PBM market dominated by four giants, raising concerns about costs, competition

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