National Alliance survey shows employers are leaving the ‘big 3’ for other PBMs

A growing percentage of employers are switching from one of the “big 3” pharmacy benefit managers (PBMs) to alternatives, according to the results of an employer survey conducted by the National Alliance of Healthcare Purchaser Coalitions.

The big 3 PBMs are CVS Caremark, Express Scripts and Optum Rx. Of the 408 employers who responded to the survey, 54.3% said this year that they use one of the big 3 as their PBM compared with 64.3% in 2025. Of the 27 employers who switched PBMs last year, 20 now contract with a PBM other than one of the big 3, the survey found. The survey results also show that among the employers considering whether to change their PBM in the next one to three years, 55.7% were currently contracting with one of the big 3 compared with 31.1% with other PBMs.

The survey found, though, that the shift away from the big 3 was largely confined to smaller employers, defined as those with fewer than 1,000 employees. Among the respondents, the percentage of smaller employers who used one of the big 3 dropped sharply from 69.7% in 2025 to 43.8% in 2026. Among larger employers — those with 10,000 employees or more — there was little change from 2025 to 2026 (75% in 2025 vs. 72.1% in 2026).

Many PBM business practices — the antagonism that they have stirred up — are rooted in rebates paid by drugmakers to the PBMs, often in exchange for the advantageous placement on the PBMs’ formularies (the lists of covered drugs). A major friction point between employers and PBMs is how much of that rebate gets passed on to the employers (and other payers) and how much is retained by the PBM. Interestingly, a greater percentage of respondents to the National Alliance’s survey who are big 3 clients indicated that they believe they get 100% rebate pass-through than those that are clients of the other PBMs (56.7% vs. 49.2%). But when it came to no spread pricing, disclosure of affiliated entities, lowest net-cost formulary and disclosure of all PBM compensation, the survey showed more favorable results for PBMs other than the big 3. The big 3 PBMs also fared worse in responses to questions about the integrity of PBM administration and the reasonableness of PBM compensation.

After years of debate, interest group lobbying and introduction of multiple, overlapping bills, Congress passed PBM reform legislation in February 2026 as part of the Consolidated Appropriations Act, 2026. Although employers, payers, and other vested interests are jockeying for position as those reforms are being introduced, legislative attention is swinging to the 340B Drug Pricing Program, which allows many hospitals, community health centers and other providers to buy outpatient drugs at discounted prices. Shawn Gremminger, M.P.P., president and CEO of the National Alliance and a member of the Managed Healthcare Executive editorial advisory board, has become a forceful critic of the program as it currently exists. The survey results show that more employers are forming a critical opinion of the 340B program. Two years ago, half of the respondents indicated that they didn’t know enough about the 340B program to have an opinion. This year, only 11% put themselves in that category, and 56% indicated that it would be very or somewhat helpful to shrink the 340B program.

The survey, which the National Alliance calls Pulse of the Purchaser, was conducted in May and June. Members of 37 employer groups organized around healthcare purchasing participated. Most (76%) of the respondents were either small (under 1,000 employees) or midsized (1,000-9,999 employees). Slightly less than half (48.2%) were self-insured, and a third (33.8%) were both fully and self-insured.

Although the survey has a number of questions about PBM, respondents were asked questions about topics ranging from expected cost increases to hospital pricing to glucagon-like peptide 1 (GLP-1) coverage. Here are a few results.

• 60.6% of the respondents expect cost increases of 7% or more in the next plan year separate from any changes in benefits.
• Respondents estimated that 30.8% of their healthcare expenditures go to hospitals and facilities; the National Alliance estimates that when all costs are considered, about half healthcare expenditures go to hospitals and facilities.
• Approximately 75% of the respondents indicated that claims data are held by their third-party administrator or health plan. Results from the survey suggest that when that happens, employers don’t have access to claims-level data.
• Employers have fiduciary responsibilities to manage pharmacy benefits and other healthcare expenditures. But the survey shows that the percentage of employers concerned about hospital charges and billing and PBM compensation as they relate to fiduciary responsibility has fallen dramatically since 2023. The survey didn’t dig into the causes but listed genuine improvement, high prices becoming normal, and attention shifting to other pressures as possible reasons.
• Just under half (49%) of the respondents said they are using centers of excellence as a strategy for dealing with hospital prices. Other strategies include site of care selection (40%), advanced primary care (32%) and direct contracting (31%).
• A large majority (85%) of the respondents indicated that they saw prior authorization as a necessary check on costs, but a sizable minority (42%) also said it puts too much of a burden on clinicians and health systems.