The U.S. pharmacy benefit management market size was estimated at USD 395 billion in 2021 and it is expected to surpass around USD 861.5 billion by 2030, poised to grow at a CAGR of 9.05% over the forecast period 2022 to 2030.
Increasing vertical integration of key market players, rising prevalence of chronic disease, and shrinking FDA generic-approval backlog are some of the primary growth stimulants for the market.
Vertical integration of pharmacy benefits management (PBM) organizations with health insurance companies are poised to result in increased control of PBMs over distribution systems. This will lead to rise in rebates, ultimately increasing the cost of drug list prices. Moreover, it will result in a monopoly of certain market player, concentrating sales and revenue generation.
The business of insuring and administering employee benefit programs in the country, especially, health care programs, is heavily regulated by federal and state laws and administrative agencies, such as the Department of Health and Human Services (HHS), State Departments of Insurance, Centers for Medicare & Medicaid Services (CMS), Internal Revenue Services, and Departments of Labor.
All PBM businesses in the U.S. must include home delivery and specialty pharmacies licensed as pharmacies in the states of establishment. Several states in the country regulate the scope of prescription (Rx) drug coverage and delivery channels to receive drugs for managed care organizations (MCOs), insurers, and Medicaid care plans. Certain home delivery and specialty pharmacies must be registered with the U.S. Drug Enforcement Administration (DEA) and individual state controlled substance authorities.
Scope of the Report
|Market Size in 2021||USD 395 Billion|
|Revenue Forecast By 2030||USD 861.5 Billion|
|Growth Rate from 2022 to 2030||CAGR of 9.05%|
|Forecast Period||2022 to 2030|
Business Model Insights
Standalone pharmacy benefits management held the leading revenue share in the market in 2021. It included major players such as CVS Health and Express Scripts who underwent major mergers by the end of 2021. The merger trend was introduced recently in this market as the Federal Trade Commission (FTC) refused many applications for mergers in the past, mainly between pharmaceutical players and PBMs.
The mergers were anticipated to allow drug manufacturers to manage pricing policies and to understand pricing information of competitors. However, the market experienced consolidations between PBMs and health insurers leading to the strengthening of key players in the market. Key mergers will be effective from 2020 along with other agreements and alliances that will change market dynamics over the forecast period.
Based on end-use, the U.S. PBM market has been bifurcated into commercial and federal. The commercial segment is anticipated to dominate the market throughout the forecast horizon. The majority of the U.S. employees are enrolled under commercial private insurance plans to benefit from the copay system for high-cost drugs.
Federal support is significant for government employees wherein premiums vary for different health plans and are paid in part by employers and employees. Employers usually pay up to 72.0% of the total amount in an average plan for self-only or family coverage while employees pay the rest.
By Business Model
By End User