For 2024, nearly 80% of all equivalent prescription claims were processed by three familiar companies: the CVS Caremark business of CVS Health, the Express Scripts business of Cigna, and the Optum Rx business of UnitedHealth Group. The names haven’t changed, but shifting relationships and contract shakeups have altered the plot, with Express Scripts stepping into a new lead role.
Below, we break down the latest market share data from Drug Channels Institute (DCI), explore the developments driving these changes, and examine what they signal for the future of the PBM landscape.
For a deeper dive into the state of the industry, join me this Friday, April 4, 2025, for our live video webinar: PBM Industry Update: Trends, Challenges, and What’s Ahead.
P.S. Special launch pricing on our new 2025 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers ends today (3/31/25)!
2024’S BIG PBM NUMBERS
DCI estimates that for 2024, about 80% of all equivalent prescription claims were processed by three companies: the Caremark business of CVS Health, the Express Scripts business of Cigna, and the Optum Rx business of UnitedHealth Group. This share was comparable to the large PBMs’ aggregate share in 2023. Note that the 80% figure refers to prescription claims processed, not to the number of covered lives handled via rebate negotiations. These data appear in Chapter 5 of our new 2025 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers.
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This concentration reflects the significant transactions and business relationships among the largest PBMs that have further concentrated market share. Five of the six largest PBMs are now owned by organizations that also own a health insurer. Like a tired sitcom rerun, smaller players were left knocking politely at the door.
Here are the key marketplace developments that have shifted PBM market share in recent years:
- Express Scripts. Express Scripts claimed the top spot for 2024.
In January 2024, Express Scripts began a five-year agreement to manage pharmacy benefits for about 20 million Centene beneficiaries. CVS Caremark had previously provided these services to Centene’s pharmacy benefit management business.
Due largely to this relationship, the total number of pharmacy customers serviced by Evernorth grew by 20%, from nearly 99 million lives in 2023 to more than 118 million lives in 2024. DCI estimates that Express Scripts’ annual retail pharmacy network claims volume grew by 531 million (+40%), from more than 1.3 billion in 2023 to nearly 1.9 billion in 2024.
- CVS Caremark. The PBM business is part of CVS Health’s Health Services segment, which includes CVS Caremark, Cordavis, Oak Street Health, Signify Health, and MinuteClinic.
For 2024, Express Scripts’ gain was CVS Caremark’s pain. Total PBM 30-day equivalent claims processed fell by −18.2%, from 2.3 billion in 2023 to 1.9 billion in 2024. The decline was largely due to the transition of Centene’s PBM business. As we discuss below, Elevance Health has acquired or launched new specialty and mail pharmacy dispensing capabilities, which also reduced CVS Caremark’s 2024 revenues and total claims managed.
- Prime Therapeutics. In 2020, Express Scripts took over retail pharmacy network contracting for a portion of Prime Therapeutics’ business. Prime acquired Magellan Rx in 2022, so Express Scripts network claims increased further as that business was transitioned during 2023. For 2024, we estimate that Express Scripts handled pharmacy network contracting for about half of Prime’s overall network spend. Consequently, we include these claims in the figures shown above.
Note that the AIDS Healthcare Foundation (AHF) successfully sued Express Scripts and Prime over this arrangement. In early 2025, an arbitrator found that Prime’s arrangement with Express Scripts violated federal and state antitrust laws.
In 2024, Prime Therapeutics announced an agreement to use Capital Rx’s JUDI technology for its pharmacy benefits administration. It’s unclear how this new relationship or the AHF lawsuit will impact the Express Scripts claims figures above.
- MedImpact. In early 2024, MedImpact Healthcare Systems, the largest privately held PBM, completed its purchase of Rite Aid’s struggling Elixir Solutions PBM business. We estimate that this slightly increased MedImpact’s claims volume, although the company has become highly secretive in recent years.
ICYMI, Rite Aid had purchased Elixir (then known as EnvisionRx) in 2015, but conspicuously failed to find any meaningful synergies as a micro-player in an increasingly consolidated market.
- CarelonRx. CarelonRx (formerly known as IngenioRx) is the PBM that the health insurer Elevance Health (formerly known as Anthem) formed in 2017. For 2024, CarelonRx’s total adjusted prescription claims volume grew by 3.2%, from 308.4 million in 2023 to 318.4 million in 2024.
However, these figures do not appear in the chart above. That’s because since 2019, CVS Health has provided such PBM administrative functions as claims processing and prescription fulfillment services for CarelonRx. Consequently, CVS Health includes the CarelonRx prescription claims within its financial reports, casting CarelonRx as the quiet guest star in this season’s very special episode.
The CVS agreement had been scheduled to end in 2024, but has been extended an additional three years, through 2027. CarelonRx has also announced multiple investments and initiatives that will expand its internal dispensing capabilities and reduce its dependence on CVS Health.
Smaller PBMs keep telling plan sponsors: Come and knock on our door, we’ve been waiting for you. But for now, three’s company, and the Big Three aren’t moving out anytime soon.
BEHIND THE NUMBERS: WHAT MR. ROPER WOULD WANT YOU TO KNOW
There are several important considerations when reviewing the figures above:
- Rebate Aggregation. The figures above do not correspond to the number of covered lives handled via rebate negotiations.
Many smaller PBMs do not have the scale to negotiate favorable formulary rebates and may lack a claims processing system. In these situations, a larger PBM acts as an aggregator for these smaller entities. The bigger PBM gets to submit a larger consolidated rebate invoice, and the smaller player gets access to better pricing and a national claims system.
Rebate aggregation also occurs via the large PBMs’ group purchasing organizations, which handle rebate negotiations with manufacturers and provide other services to manufacturers and the groups’ members. To date, these groups are focused on commercial, nongovernmental business. The three major PBM-owned purchasing groups include Ascent Health Solutions (Cigna/Evernorth), Emisar Pharma Services (UnitedHealth Group/Optum), and Zinc Health Services (CVS Health). We profile these GPOs in Section 5.2.4. of our new pharmacy/PBM report.
Due to this aggregation, there is substantial double counting when evaluating covered lives. Summing up the figures reported by individual PBMs results in an aggregate number that greatly exceeds the total U.S. population.
- Claims processing and pharmacy network management. The figures for the largest companies include an unknown number of claims from smaller PBMs. That’s because many smaller PBMs outsource claims processing and fulfillment to one of the three largest PBMs. Smaller PBMs with internal capabilities are included in the “All Other PBMs” category.
- Discount cards. Patient-paid prescriptions that use a discount card are not considered cash-pay, because the claims are adjudicated by a PBM. A growing (but undisclosed) share of discount card claims are included within the figures for each PBM.
We reserve the term cash-pay prescription for claims that are not submitted and adjudicated, so a PBM or third-party payer has no record of drug utilization. Instead, the patient is the payer and there is no PBM involvement.
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