Meanwhile, plan sponsors are inviting alternatives into their RFPs, and some are changing vendors. Research on 2027 benefits planning suggests the shopping will continue.
That combination points to a new test for alternative PBMs—one where they have to turn their pitch into value that plan sponsors continue to see after they sign a contract.
Below we examine the shrinking satisfaction advantage, the choices plan sponsors are considering for 2027, and why the grass may not always be greener on the alternative PBM side.
A CLOSER LOOK AT THE OTHER SIDEDrug Channels Leadership Forum 2027
The Drug Channels Leadership Forum agenda is now available! Explore the agenda and request your invitation to this invite-only gathering of senior leaders from across the drug channel ecosystem. You must request an invitation to be considered for attendance.
The new 2026 Pharmacy Benefit Manager Customer Satisfaction Report from Pharmaceutical Strategies Group (PSG) evaluated PBM satisfaction by surveying 250 benefits leaders including employers, health plans, health systems, and unions or Taft-Hartley plans representing approximately 144 million covered lives. Nearly two-thirds of the plans used CVS Caremark, Express Scripts, or Optum Rx (the “Big Three” PBMs).
Overall satisfaction with PBMs rose slightly, from 7.1 to 7.2 on a 10-point scale. The more interesting piece is the trend within the two PBM groups:
- Big Three customers: Satisfaction increased from 6.8 to 7.1. That still leaves the group below its 2024 score of 7.4.
- Non-Big Three customers: Satisfaction fell from 7.9 to 7.3. This accounts for most of the narrowing in the satisfaction gap between the groups.
Non-Big Three customers' Net Promoter Score (NPS) also fell from +16 to +4. Their rating of services relative to expectations declined from 7.1 to 6.5. Their three-year likelihood of renewing without a competitive RFP fell from 7.3 to 6.8. These measures point to falling excitement among non-Big Three customers, not just a lower overall satisfaction score. That's a red flag for PBMs trying to turn RFP wins into durable client relationships.
This is at the same time that Big Three customers' expectations and renewal ratings held at 6.2 and their NPS remained negative at -22. Non-Big Three PBMs still retain an advantage, but across several measures, their clients are becoming less enthusiastic.
THE GRASS LOOKS GREENER
Non-Big Three PBMs also maintain an advantage on perceived transparency. Their customers gave higher ratings in all six areas PSG measured.
The largest gap was for sources of revenue. The exhibit below shows how the perception of PBMs can vary by PBM size. Perceived transparency around rebates has improved compared to last year. However, across all PBMs, revenue transparency remained the lowest-rated category, which was unchanged from 2025.
[Click to Enlarge]
A better relative score for alternative PBMs, then, does not mean plan sponsors have stopped asking where the money goes. That scrutiny should extend to affiliated pharmacies, rebate GPOs, and subcontracted services. As we covered in our PBM webinar in April, many new vendors subcontract services from major PBMs. Changing the company on the contract does not necessarily remove every economic connection to a Big Three PBM.
You can find much more on the alternatives to the Big Three PBMs in Section 5.2.3. from our 2026 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers.
SEARCHING FOR GREENER PASTURES
This is happening as alternative PBMs (used in this article as equivalent to non-Big Three PBMs) are getting more opportunities to compete. In PSG's survey, 69% of respondents included at least one non-Big Three PBM in their most recent RFP. Over 80% of respondents were at least moderately interested in including one in their next procurement. However, it doesn’t mean those PBMs won the business or that clients were more satisfied after switching.
The 2026 Pulse of the Purchaser survey from the National Alliance of Healthcare Purchasers Coalitions provides some evidence that plans are changing PBMs, not just talking about it.
Of 27 employers reporting a PBM change in the past year, 20 now use a non-Big Three PBM and seven use a Big Three PBM. The Big Three’s share among survey respondents fell from 63.4% in 2025 to 54.3% in 2026, but the decline was concentrated among small employers. These results are shares of survey respondents, not national prescription market shares, so they are unlikely to move PBM prescription market share much.
The annual samples differed for this survey, and the PBM question changed from an optional write-in to a pick-list. Treat the year-over-year comparison as a general trend.
More changes may be coming. Among current Big Three clients, the survey found 56% were considering a PBM change within one to three years, compared with 31% of all other PBM clients. Other recent employer surveys are returning similar results.
However, the competitive opportunity runs in both directions. Alternative PBMs can win clients looking for a different approach. The Big Three can also retain some of those clients by offering different contract arrangements, as they have all begun to do.
THE NET COST OF JUMPING THE FENCE
The factors that plan sponsors use to select their PBM help explain why getting onto the RFP list does not guarantee winning the business.
Pricing remains the dominant selection factor. PSG survey respondents selected pricing as the most important factor in 70% of the MaxDiff comparisons in which it appeared. Below is a breakdown by type of plan sponsor.
[Click to Enlarge]
Combined, honoring guarantees and commitments ranked second, moving up two spots compared to 2025. Plan sponsors appear to value delivering on promises more than in the past.
When asked for their single leading reason to leave their current PBM, 50% chose better pricing. A distant second was price transparency with 14%.
For an RFP, the practical issue is defining what price really means. Many plans and consultants just compare discount guarantees, rebate guarantees, and an administrative fee between competitors. Determining what the plan will actually spend requires consistent assumptions about its claims, formulary, utilization, fees, and contractual exclusions.
A proposal from a PBM can look attractive on those individual guarantees and deliver a much less green cost. Plan sponsors need to compare each proposal’s total net cost with the value and service it offers relative to competing proposals, and that’s a much tougher exercise.
IS THE GRASS REALLY GREENER?
Alternative PBMs still have a slight satisfaction lead and are getting more consideration from plan sponsors, but their lead has narrowed and several measures suggest weaker enthusiasm among their customers.
In my view, that places alternative PBMs at an important point. Transparency and an alternative model can help win attention, but lasting differentiation will depend on whether clients continue to see value in the contract and the service they receive.
Transparency can help plan sponsors evaluate bids when they use the information effectively, but ultimately the PBM will have to deliver on net cost, service, and its commitments.
Can the alternative PBMs keep the grass green now that they have a few more people stomping around on their side of the fence?
No comments:
Post a Comment