Watch out Big 3—alternative pharmacy benefit managers (PBMs) are coming for you.
Amid rising drug costs, lawsuits, and federal scrutiny, employers are increasingly looking for new ways to manage their pharmacy benefits outside the Big 3 PBMs: CVS’s Caremark, Cigna’s Express Scripts, and UnitedHealth’s Optum Rx, which collectively control about 80% of the pharmacy market.
A September report from nonprofit trade group the National Alliance of Healthcare Purchaser Coalitions, found 61% of the 324 employers surveyed have moved away from using the three major PBMs in the past year or are considering moving away from them within the next three years.
“The heightened awareness around the large three PBMs in the market really took off last year, and that has made a lot of plan sponsors curious to explore different options in the industry,” Alysha Fluno, national pharmacy practice leader at consulting firm Mercer, told Healthcare Brew.
Why? There are a couple of factors that have pushed PBMs into the spotlight, Fluno said.
For one, there were several high-profile lawsuits in 2024 in which employees sued their companies for allegedly neglecting their fiduciary responsibilities by allowing PBMs to overcharge for prescription drugs. JPMorgan, Johnson & Johnson, and Wells Fargo all faced such lawsuits, though those against the latter two companies have since been dismissed.
Employers want to make sure they aren’t going to face similar legal action, Fluno said, so they’re looking at their PBM contracts and evaluating options.
Second, the Federal Trade Commission released multiple reports last year that were highly critical of PBM practices. The agency also sued the three major PBMs in 2024, accusing them of inflating insulin prices (though the agency halted that lawsuit in April after the Trump administration took over).
Who are these new players? Among the newer alternative PBMs are AffirmedRx and Rightway.
AffirmedRx was founded in 2021 and says on its website that its mission is to “transform pharmacy benefit management” and “champion transparency” in its pricing model, as opposed to the complex and opaque pricing structures many accuse the Big 3 of practicing. The major PBMs, for example, consider the amount they reimburse pharmacies per prescription to be trade secrets, as we previously reported.
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AffirmedRx gained some large clients in 2025, including the convenience store chain 7-Eleven and Indiana-based Purdue University.
Rightway was founded in 2017 and the PBM passes through 100% of rebates to its employers and lowered pharmacy spend for its clients by about 16% in year one, according to the company’s 2024 annual report. Tyson Foods switched from CVS’s Caremark to Rightway in early 2024.
Other alternative PBMs include Navitus Health Solutions, Liviniti, SmithRx, MedOne Pharmacy Benefit Solutions, and RxPreferred.
“The PBM market is competitive and diverse,” Greg Lopes, spokesperson for PBM trade group the Pharmaceutical Care Management Association, told Healthcare Brew via email. “Across this competitive industry is a common mission—to help patients access and afford the drugs they need.”
Changing it up. In response to these newer PBMs coming on to the market, the Big 3 PBMs are starting to offer alternative approaches to managing pharmacy benefits, Fluno said.
For example, pharmacy contracts have historically been based on a pricing metric called the average wholesale price, or AWP. But some PBMs are starting to offer contracts with different pricing models, such as a per-member-per-month model, Fluno said, which is a fixed fee based on the number of members in a health plan, as opposed to negotiating a discount based on the AWP.
CVS’s Caremark, for example, launched its TrueCost pricing model in 2024, which is based on the cost of a drug plus a dispensing fee and administrative fee, similar to the idea behind Mark Cuban’s Cost Plus Drugs model. According to Fluno, TrueCost is “a very unique approach in the [PBM] market.”