Big Three PBM Use Falls, Transparent PBM Use More Than Doubles, Annual Survey Shows

Employer use of transparent PBMs have more than doubled in the past year, compared with employer use of the Big Three PBMs, according to the results of the 2025 Pulse of the Purchaser survey, conducted by the National Alliance of Healthcare Purchaser Coalitions (National Alliance) and its member coalitions.

The “Big Three” PBMs—CVS Caremark, Express Scripts and OptumRx—controlled approximately 57% of the market in 2023. However, in the last year, employer use of the Big Three has fallen from 72% to 61%, while employer use of transparent PBMs has risen from 12% to 31%, the survey notes. Additionally, other PBM use has declined from 16% to 8%.

Most employers (53%) also strongly agree that rising healthcare costs impact their ability to compete. In 2022 only 35% of employers strongly agreed with this statement.

“A survey respondent aptly described the current healthcare environment as a dumpster fire with unlimited fuel as long as employers continue to put up with the status quo,” Shawn Gremminger, National Alliance president and CEO, said in a news release. “U.S. healthcare costs continue to grow exponentially and outpace economic growth, and it’s the innovative employers that have access to their claims data that are paving the way to fair prices and equitable access.”

This year’s survey included 324 employers from private and public employers and purchasers from across the country. Results were collected from July to August 2025.

The National Alliance of Healthcare Purchaser Coalitions is a nonprofit organization that represents coalitions of employers and other healthcare purchasers, specifically private and public sector employers, nonprofits and labor unions.

Read the slideshow below for survey highlights.

The full Pulse of the Purchaser survey results can be found here.