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Employers with fewer than 1,000 cut ties with top PBMs
A 2026 survey found the Big Three PBM share fell most sharply among small firms, dropping 26 points to 43.8% from 69.7% over one year.
The share of employer-sponsored health plans using one of the three largest pharmacy benefit managers, CVS Caremark, Express Scripts, or OptumRx, fell nine points over one year, declining to 54.3% in 2026 from 63.4% in 2025, according to a 2026 Pulse of the Purchaser survey published by the National Alliance of Healthcare Purchaser Coalitions and covered by Insurance Business.
The report said the shift was driven almost entirely by employers with fewer than 1,000 employees. Among that group, the share naming a Big Three PBM dropped 26 points, from 69.7% in 2025 to 43.8% in 2026. By contrast, the share was roughly flat for mid-size employers, about 51% in both years, while large employers edged down from 75% to 72.1%, which the report described as directional rather than statistically meaningful.
Insurance Business reported that the National Alliance CEO Shawn Gremminger said larger PBMs are better positioned to handle the claim volume associated with large employers, which helps explain why the largest plan sponsors are less likely to move. The survey also showed switching intent rises with employer size, with 47.4% of under-1,000 employers considering a change, versus 57.4% for those with 1,000 to 9,999 employees and 60.4% for those with 10,000 or more.
The report cited by Insurance Business also noted that among employers that changed PBMs in the past year, 20 now use a non-Big Three manager and seven use a Big Three PBM, and it found non-Big Three clients were more than twice as likely to have switched recently, at 24.4%, compared with 11.3% for current Big Three clients. The data reflect the views of participating employers in the National Alliance member network rather than all plan sponsors nationwide.