When an employee picks up a prescription at the pharmacy, they’re not typically aware of the complex negotiations that took place behind the scenes to land on a price for the medication. But HR leaders are increasingly placing these negotiations on their radars, in part due to scrutiny surrounding pharmacy benefit managers (PBMs). These intermediaries work with both drugmakers and insurers to determine how much health plans pay for prescription drugs, and are seen as part of the cost of doing business for benefits teams that oversee health plans. The PBM industry is dominated by three major players—CVS’s Caremark, Cigna’s Express Scripts, and UnitedHealth Group’s Optum Rx—but that competitive landscape is beginning to shift, prompting some employers to look elsewhere. We talked to benefits leaders and healthcare consultants about what that transition entails, and why most employers are still sticking with the Big 3. PBMs under scrutiny. In recent years, PBMs have come under scrutiny for allegedly artificially inflating the cost of drugs, giving special perks to their vertically integrated pharmacies and insurance companies, and pocketing rebates. See our latest collaboration with HR Brew here.—MA, CV | 
