Pharmaceutical drug prices continue soaring up and contribute significantly to total healthcare expenditure worldwide. The cost of drugs has risen more than any of the healthcare expenditure. According to Milliman, an actuarial and consulting firm, prescription drug costs increased from 13.2% in 2001 to nearly 15.9% of the overall health spending for a family of four in 2015. Rising drug prices and increasing consumer spending on prescription drugs drives demand for pharmacy benefit managers (PBMs). The pharmacy benefit management system is operated by third party administrators (TPAs) who act as a liaison between pharmacists, insurance providers (payers), and drug manufacturers. There are established companies offering these services who aid in reducing drug prices by negotiating with retail pharmacies and drug manufacturers. Patients who have enrolled in various health plans and those uninsured can get the benefits of pharmacy benefit management system. Health plans collaborate with the pharmacy benefit managers to offer medications at a lower price than those available at retail pharmacies.

Moreover, PBMs also aid in planning and managing the formulary as per customer needs, negotiating discounts and rebates with drug manufacturers, contracting with pharmacies, and processing the prescription claims. To manage the cost of prescription drugs and improve the customer value, PBMs use various tools such as pharmacy networks, mail-service pharmacies, drug formulary, e-prescribing, manufacturer’s discount, disease management, drug utilization review, and pharmacy discount cards (for the uninsured). To manage these tools and the PBMs account, there are various prescription claim software/systems marketed worldwide.

Pharmacy Benefit Management Market Taxonomy

The global pharmacy benefit management market can be analyzed on the basis of the beneficiaries of these services i.e. the healthcare providers, employers, and drug manufacturers. A major population in the U.S. receives healthcare benefits from their employers. Therefore, employers are also seeking to reduce their costs and opt for pharmacy benefit management services. The providers of pharmacy benefit management services also manage the prescription drug claims i.e. act as a link between the payers and health insurers.

The Pharmacy Benefit Management Market is Highly Concentrated in Developed Markets

The global market in pharmacy benefit management is analyzed across five major regions - North America, Europe, Asia Pacific, Latin America, Middle East, and Africa. Presence of PBM is concentrated in the developed economies of North America and Europe. Increase in subscribers of Medicare prescription drug program is projected to fuel demand for PBMs in the U.S. Besides, the pharmacy benefit managers also aid in deciding whether a generic or branded product would benefit the patient. Patents for around 40 blockbuster brands worth US$ 155 billion are expected to expire by 2020. Generics have a good profit margin, which can benefit the pharmacy benefit managers/management companies, thus favorably shaping the pharmacy benefit management market outlook. Similar scenario is observed in the Europe pharmacy benefit management industry.

Challenges faced in the Pharmacy Benefit Management Market

With the introduction of expensive treatments/drugs for chronic diseases such as cancer, and hepatitis, demand for PBMs is projected to increase significantly. However, even with the presence of major players in this industry, the PBMs have been ineffective in curbing the drug price hike. Further, with the advent of Affordable Care Act and the constant endeavor of governments to reduce and cap the drug prices, profitability of this industry is expected to be significantly impacted in the near future.

Some of the major players present in the global pharmacy benefit management market include Express Scripts, CVS Caremark, Prime Therapeutics, United Health / OptumRx, Catamaran Corporation, Humana Pharmacy Solutions and MedImpact. Express Scripts acquired Medco Health Solutions for US$ 29.1 billion in April 2012, making it a leader with a significant share in the global pharmacy benefit management industry. With increasing competition, industry consolidation is expected to be a prevalent trend in the near future.

Key Developments

Key players in the market are focused on launching new pharmacies and benefit programs to expand their market share. For instance, in August 2019, Accredo, a specialty pharmacy, started a new, full-service pharmacy for residents of Hawaii who require additional clinical and administrative support for their complex treatments and medications.

Similarly, in July 2019, Aetna, a CVS Health company, started offering fully insured health care network options to its Preferred Product Organization (PPO), Exclusive Product Organization (EPO), and Health Maintenance Organization (HMO) product portfolios through Aetna Whole HealthSM - Southern California.

In April 2019, Express Scripts, a pharmacy benefit managers, and Appriss Health, provider of prescription drug monitoring platform, developed a Prescription Drug Monitoring Program (PDMP) for the Military Health System (MHS).