The share of employers using one of the three major pharmacy benefit managers — Optum Rx, CVS Caremark, or Express Scripts — fell from 63.4% in 2025 to 54.3% in 2026, according to the National Alliance of Healthcare Purchaser Coalitions’ Pulse of the Purchaser survey. The drop was driven largely by employers with fewer than 1,000 employees.
Further shifts may be coming. Nearly 56% of clients of the three major PBMs are considering a change within one to three years, compared with 31% of those using other PBMs. These clients were also more likely to report higher-than-average premiums (38.5% vs. 27.5%).
Other pharmacy findings from the survey:
- Drug prices remain a major concern. 77% of employers identified them as a top threat to affordability, while prescription drugs were estimated to account for 21.1% of total health care spending.
- Recent PBM changes favor alternatives. Of the employers that reported changing PBMs in the past year, 74% currently use a PBM outside the three major companies, compared with 26% that use one of the three.
- PBM oversight remains a concern. Clients of the three major PBMs were nearly three times as likely as other PBM users to question the integrity of PBM administration and the reasonableness of PBM compensation.
- Employers want reform. Nearly 88% said PBM reform would be very or somewhat helpful — the highest-rated policy change tested in the survey.