The expensiveness and lack of transparency in the current medical system in the US has driven up dependence on healthcare system and lead to costs spiraling out of control. This is driving demand for pharmacy benefit management (PBM) to help stem costs.
Plan sponsors are looking at supplemental benefits that can help to reduce medical cost burden and drive better outcomes beyond the regular pharmacy and medical benefits. Digital health solutions from PBMs are thereby in demand.
PBMs have been tangled in the bureaucracy. They are being criticized as contributing to the ineffectiveness, expensiveness, and bad service of the US healthcare system at the behest of pocketing profits.
PBMs are reinventing themselves and reinforcing the roles they play in the healthcare system by shifting from a siloed mindset to vertical integration by combining with specialty pharmacies and insurers.
The future of PBMs is going to be dictated by the implementation of state and national-level policies with respect to revenue streams and business practices in the pharmaceutical space.
Market Size & Forecast by Revenue | 2019−2025
Market Dynamics – Leading trends, growth drivers, restraints, and investment opportunities
Market Segmentation – A detailed analysis by services, health plan, and business model
Competitive Landscape – Profile of 7 key vendors and 31 other vendors
The U.S. healthcare landscape is complex. It is riddled with wastage, drug abuse, and fraud due to a whirlwind of causative factors, putting patients at risk and creating a dilemma for insurers. It translates to high out-of-pocket costs, increased incidences of inappropriate spending, higher premiums, reduced benefits or coverage for consumers, increases cost of doling out insurance benefits for governments, and private employers. With a high number of consumers being enrolled in high-deductible health plans, there is a need for coordinated and broad effort to fix loopholes. Pharmacy benefit managers are well-positioned as patients advocate to work with players across the board, with every member in the healthcare industry. PBM pharmacists can witness a complete picture of the member's medication background. This has enabled them to drive awareness among pharmacists and doctors/physicians to identify challenges and enable the delivery of better treatment through better communication and care coordination across the healthcare continuum for each patient.
The following factors are likely to contribute to the growth of the pharmacy benefit management market in US during the forecast period:
Foray into Digital Health Solutions
Growth in FDA Approvals for Orphan and Specialty Drugs
Shift to Value/Outcomes-based Contracts
Increased Engagement in High-touch Care Management
The study considers the present scenario of the pharmacy benefit management market in US and its market dynamics for the period 2019−2025. It covers a detailed overview of several market growth enablers, restraints, and trends. The study offers both the demand and supply aspects of the market. It profiles and examines leading companies and other prominent ones operating in the market.
Pharmacy Benefit Management Market in US: Segmentation
This research report includes a detailed segmentation by services, health plan, and business model. Specialty pharmacy - a segment of the U.S. Pharmacy Benefit Management market, which is a collaborative, clinical, integrated environment, is recording significant growth in the US pharmacy benefit management market. The segment has cemented its place in the continuum of healthcare, backed by a healthy level of activity in payer access and data systems. As specialty drugs have outpaced all the other elements of healthcare costs, the segment is keeping payers on the edge of their seats. Since specialty pharmacies and mail-order pharmacies operate on a similar model in terms of medication deliveries. There are apprehensions about conflicts of interest and about how PBMs tag specific drugs as "specialty."
Drugs, which treat auto-immune conditions, are growing at the fastest rate in commercial health plans. With emerging therapies that come at a high cost, the per-member, per-month spending on these therapies has witnessed an upward trend over the past couple of years. The increased focus of commercial health plan providers is on monitoring use and keeping the cost of drugs in check. This has led to an increased focus on utilization monitoring and formulary design, driving better prospects for the segment.
Commercial plan sponsors are also looking to increase resources to help employees access behavioral and mental health services as they struggle with maintaining the usefulness of prescription management services. The enrollment in Medicare Part D plans has grown 2X times over the last 15 years. Seeing as Medicare is designed to absorb risk, providing for individuals with complex, expensive medical needs, along with relatively healthy individuals, these plans rely heavily on PBMs.
The Pharmacy benefit management market in US is well backed, fortifying future growth by ramping up the capital investment in data analytics capabilities and technology R&D. As employers continue to concentrate on whole-person health, providing a total benefits solution, which is vital to draw and keep talent, this segment is expected to grow.
As insurance companies launch new products for gene therapies, they are considering offering therapy management techniques. The key players in the market are keeping a tab on the gene therapy pipeline and tracing patient outcomes, which are being used as a starting point for value-based arrangements that the company is on with pharma manufacturers. This is drawing attention, particularly from employers, creating favorability for players with these business models. The pharmacy benefit management market in US is highly fragmented.
The Pharmacy Benefit Management market in US share has changed considerably in the last couple of years, where acquisitions led the market to where it is today, occupied mostly by a couple of giants. As a result, the PBM industry is highly concentrated with Caremark, Express Scripts, and OptumRX, accounting for more than 70% of claims volume. They have been the shapeshifters in the PBM space. However, that again is changing as insurers have been building their presence in the market by dissolving existent relationships with PBMs and acquiring or launching their own.
Humana Pharmacy Solutions
Other Prominent Vendors
Magellan Rx Management
Navitus Health Solutions
Key Questions Answered
What is the U.S. Pharmacy Benefit Management Market Size in 2020?
What is the growth rate (CAGR) of the U.S. PBM Market during 2020-2025?
Which is the leading segment of the U.S. PBM Market?
Impact of COVID-19 on the Pharmacy Benefits Management Market in the U.S.?
Arizton Advisory and Intelligence is an innovation and quality-driven firm, which offers cutting-edge research solutions to clients across the world. We excel in providing comprehensive market intelligence reports and advisory and consulting services.
We offer comprehensive market research reports on industries such as consumer goods & retail technology, automotive and mobility, smart tech, healthcare, and life sciences, industrial machinery, chemicals and materials, IT and media, logistics and packaging. These reports contain detailed industry analysis, market size, share, growth drivers, and trend forecasts.
Arizton comprises a team of exuberant and well-experienced analysts who have mastered in generating incisive reports. Our specialist analysts possess exemplary skills in market research. We train our team in advanced research practices, techniques, and ethics to outperform in fabricating impregnable research reports.