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PBM-affiliated private label biosimilars would seem to have a built-in formulary advantage. But for ustekinumab, that advantage has not carried over to Medicare Part D.
A recent JAMA Network Open study identified 12 ustekinumab products available for formulary coverage in early 2026. Yet the average Part D plan covered only 2.3 biosimilars. Even more surprising, PBM affiliated private label products were largely missing from formularies connected to their corporate siblings.
CVS Health’s Cordavis labeled Pyzchiva received no Part D coverage. Optum Rx’s Nuvaila labeled Wezlana appeared in just 0.4% of UnitedHealth plans.
The results run against the conventional logic of vertical integration. If a PBM can influence formulary placement, why not direct volume toward its own product like in commercial formularies? The answer lies in the Inflation Reduction Act’s (IRA) Part D redesign, which made the economics of an affiliated private label biosimilar potentially less attractive in Medicare than in the commercial market.
Below, we follow the incentives that help explain why PBM-affiliated biosimilars remain largely absent from Medicare Part D formularies.
For 2026, the three largest pharmacy benefit managers (PBMs)—Caremark (CVS Health), Express Scripts (Cigna), and Optum Rx (United Health Group)—have once again excluded hundreds of drugs from their standard formularies. Our updated counts appear below.
The 2026 lists highlight how formulary preferences for Humira and Stelara are dominated by private-label biosimilars affiliated with the same parent companies that operate the three largest PBMs. Many of the preferred products feature lower list prices, signaling growing tension between traditional rebate-driven formularies and emerging net-price-based competition.
These developments matter because the pricing system that underpins PBMs’ formulary leverage is weakening. The gross-to-net bubble is deflating and the industry is moving toward what we call the Net Pricing Drug Channel (NPDC).
As low list prices, direct-to-patient distribution, and cost-plus reimbursement models gain traction, formulary exclusions will no longer deliver the economic power they once did. These changes threaten PBMs’ leverage—and profits.
As usual, Mark Cuban is leading the way. AbbVie itself now appears to be following. Consider this year’s formulary review a preview of what market access looks like when the rebate game starts to unwind.
On March 24, 2026, Drug Channels Institute will release The 2026 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers. This report—our seventeenth edition—remains the most comprehensive, fact-based tool for understanding the entire U.S. drug pricing, reimbursement, and dispensing system. If you make strategic decisions in this industry, this report belongs on your desk.
12 chapters, 500+ pages, 270 exhibits, and nearly 1,300 endnotes. No other resource matches the scope, depth, and rigor of this resource.
We are offering you the opportunity to preorder the thoroughly updated, revised, and expanded 2026 edition at special discounted prices. Preordering guarantees early access and locks in the lowest available price. Those who preorder will receive a download link before March 30.
Special preorder and launch pricing discounts will be valid through April 6, 2026. After that date, prices increase. Secure your discount now.
The report was researched and written by the Drug Channels Institute team, led by Adam J. Fein, Ph.D. As shown below, the 2026 edition delivers unmatched depth and breadth. The numbers indicate the report chapter that corresponds to, explains, and analyzes each channel flow.
The 2026 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers contains the most current market and industry data available, including DCI’s annual analyses of the market positions of the largest pharmacies, specialty pharmacies, and PBMs. Throughout the report, we have added new industry data, deepened our coverage of many topics, and expanded our analysis of emerging trends.
This definitive, nonpartisan report will aid pharmaceutical manufacturers, wholesalers, pharmacists, pharmacy owners, hospital executives, pharmacy buyers, benefit managers, managed care executives, policy analysts, investors, consultants, and anyone else who wants to understand and benefit from this ever-changing industry. If your organization competes, negotiates, invests, or sets policy in this market, this report will sharpen your strategy.
There are many notable updates in this 2026 edition, including:
A new Section 4.3.4. analyzes manufacturers’ direct-to-patient (DTP) websites and TrumpRx within the broader context of patient-paid prescriptions.
A new Section 5.5. deconstructs the three largest PBMs’ gross profits. Some of this material previously appeared in Chapter 11.
Material in Section 7.1., Section 9.1., and Section 9.3. reflects the PBM legislative reforms contained within the Consolidated Appropriations Act, 2026 (P.L. 119-75), which became law in February 2026.
Material in Section 8.4. and Section 9.3. incorporates implications of the 2026 settlement between Express Scripts and the Federal Trade Commission.
A new Section 6.3.3. reviews research on how the IRA’s implementation has affected out-of-pocket spending by Medicare Part D beneficiaries.
A new Section 11.2.4. analyzes pharmacies’ dispensing profits under the Inflation Reduction Act of 2022 (IRA).
A new Section 12.1.4. evaluates the potential implications of most favored nation (MFN) and tariff policies on the drug channel.
In Section 12.3.1., our illustration of major vertical business relationships among drug channel businesses now incorporates affiliated third-party administrators (TPAs) and administrative services only (ASO) platforms.
We have also improved our presentation of material about the IRA and the 340B Drug Pricing Program.
Thank you for your interest in our work. If you have any questions before purchasing a license to the report, please email me. We look forward to supporting your team’s success in 2026.
Super Bowl LX is almost here! Time for some blowout beer and snack commercials, occasionally interrupted by an actual football game. DCI’s hometown Philadelphia Eagles will not be going to the big game, so the city’s light poles will remain Crisco-free and upright.
While you wait for kickoff, please enjoy this month’s playbook of articles, intercepted for you from the Drug Channels gridiron:
For 2026, the three largest pharmacy benefit managers (PBMs)—Caremark (CVS Health), Express Scripts (Cigna), and Optum Rx (United Health Group)—have once again excluded hundreds of drugs from their standard formularies. Our updated counts appear below.
The 2026 lists highlight how formulary preferences for Humira and Stelara are dominated by private-label biosimilars affiliated with the same parent companies that operate the three largest PBMs. Many of the preferred products feature lower list prices, signaling growing tension between traditional rebate-driven formularies and emerging net-price-based competition.
These developments matter because the pricing system that underpins PBMs’ formulary leverage is weakening. The gross-to-net bubble is deflating and the industry is moving toward what we call the Net Pricing Drug Channel (NPDC).
As low list prices, direct-to-patient distribution, and cost-plus reimbursement models gain traction, formulary exclusions will no longer deliver the economic power they once did. These changes threaten PBMs’ leverage—and profits.
As usual, Mark Cuban is leading the way. AbbVie itself now appears to be following. Consider this year’s formulary review a preview of what market access looks like when the rebate game starts to unwind.
In recent years, these companies have spent more than $16 billion to acquire management service organizations (MSOs) that oversee physician practices in such specialties as gastroenterology, oncology, ophthalmology, and urology.
Below, we highlight the largest MSO transactions and explore five ways wholesalers benefit from ownership in their downstream physician customers. Ultimately, these strategies may allow wholesalers to exert unprecedented control over market access for provider-administered drugs—if they can figure out how to realize this power.
Happy Thanksgiving, everyone! Before you stretch your stomach, stretch your mind with some fresh food for thought from across the drug channel. In this issue:
What else should you expect for 2026? Find out during my upcoming live video webinar, Drug Channels Outlook 2026, on December 12, 2025, from 12:00 p.m. to 1:30 p.m. ET. Click here to learn more and sign up. As always, we are offering special discounts if you want to bring your whole team.
In recent years, these companies have spent more than $16 billion to acquire management service organizations (MSOs) that oversee physician practices in such specialties as gastroenterology, oncology, ophthalmology, and urology.
Below, we highlight the largest MSO transactions and explore five ways wholesalers benefit from ownership in their downstream physician customers. Ultimately, these strategies may allow wholesalers to exert unprecedented control over market access for provider-administered drugs—if they can figure out how to realize this power.
Special launch pricing is available through October 27, 2025.
This report—our sixteenth edition—remains the most comprehensive, data-driven resource for understanding and analyzing the large and growing U.S. pharmaceutical distribution industry.
With 9 chapters, more than 400 pages, 187 exhibits, and over 850 endnotes, this report is unmatched in scope and depth. There’s simply no other resource like it.
Order today to secure your copy of this fully updated, revised, and expanded 2025-26 edition at special discounted prices.
The 2025-26 Economic Report on Pharmaceutical Wholesalers and Specialty Distributors remains the most comprehensive, fact-based tool for understanding and analyzing the large and growing U.S. pharmaceutical distribution industry. Widely regarded as the industry standard, this encyclopedic resource offers a definitive guide to wholesale distribution’s role in the complex web of U.S. prescription drug channels.
The chart below illustrates the vertical integration and broad reach of the three largest companies in U.S. pharmaceutical distribution. The numbers in the chart correspond to the report chapter that explains and analyzes the specific business segment.
Updated analyses of strategies, market positions, and executive compensation for the Big Three—Cencora, Cardinal Health, and McKesson. We review each company’s business segments and underlying business profitability, based upon our proprietary economic models. This allows you to assess differences among the public companies’ organizational structure and financial performance.
Self-contained chapters that do not need to be read in order. (Really!) There are loads of internal hyperlinks to help you navigate the document and customize it to your specific interests and priorities.
The option to download an additional PowerPoint file with images of all 178 exhibits. This popular option helps you share the insights and data with others in your organization. (The exhibits appear within the text for all license versions.)
760 (!) endnotes, most of which have direct hyperlinks to original source materials for deeper learning.
No SpongeBob Squarepants, corny jokes, or pop culture references, all of which have been reluctantly removed.
Thank you for your continued interest in our research. Please email me (afein@drugchannels.net) with any questions before purchasing.
We look forward to sharing this year’s insights with you.
The 2025 launch of biosimilars to Johnson & Johnson’s Stelara (ustekinumab) marks another turning point in pharmacy benefit dynamics. But unlike the chaotic rollout of Humira biosimilars, pharmacy benefit managers (PBMs) came prepared.
Private label strategies, aggressive pricing, and exclusive formulary deals have transformed what might have been a slow-crawling biosimilar introduction into a full-on pricing war. As with Humira, the reality of biosimilar economics is far messier—and more revealing—than the policy narratives suggest.
In this post, I examine how the major PBMs—and some of the smaller ones—are handling Stelara biosimilars, what’s changed since the Humira experience, and why their strategies reflect the growing dominance of private-label rebating schemes.
As always, with great pricing power comes great responsibility. Excelsior!
Drug Channels Institute is proud to host the 2026 Drug Channels Leadership Forum, which will take place from March 16–18, 2026, in Miami. Check out 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. We will begin sending invitations in mid-October.
With 9 chapters, 400+ pages, 187 exhibits, and 850+ endnotes, this report is unmatched in scope and depth. There is no other resource like it.
Preorder today to secure this fully updated, revised, and expanded 2025-26 edition at special discounted prices. Preorders ensure early access. You’ll receive the report before its October 14 release date.
Special preorder and launch pricing discounts will be valid through October 27, 2025. Act now to maximize savings.
The chart below highlights the three largest companies’ vertical alignment and diverse roles within the U.S. healthcare system. The numbers in the chart indicate the report chapter that corresponds to, explains, and analyzes each business.
[Click to Enlarge]
The 2025-26 Economic Report on Pharmaceutical Wholesalers and Specialty Distributors remains the most comprehensive, fact-based tool for understanding and analyzing the large and growing U.S. pharmaceutical distribution industry. Widely regarded as the industry standard, this encyclopedic resource offers a definitive guide to wholesale distribution’s role in the complex web of U.S. prescription drug channels.
Our 2025-26 edition contains the most current financial and industry data about the distribution of pharmaceuticals and the major companies that handle these products. As always, we have updated all market and industry data with the most current information available. The report also updates our annual analyses of the strategies, market positions, and executive compensation of the three largest companies: Cencora, Cardinal Health, and McKesson.
We review each wholesaler’s business segments and underlying business profitability, based upon our proprietary economic models. This information allows you to assess differences among the public wholesalers’ business organizations, strategies, and financial performance. Where appropriate, financial data have been restated based on updated disclosures.
Thank you for your continued interest in our research. Please email me (afein@drugchannels.net) with any questions before purchasing. We look forward to sharing this year’s insights with you.
Our news-laden summer is ending. Time to pack away your bathing suit, send the kids back to school, and cherish these curated curiosities that I combed from the Drug Channels coastline:
After multiple years of mandated disclosure of negotiated hospital-insurer rates, those of us who follow the buy-and-bill channel might have expected transparency to reduce drug price variability, lower hospital markups, and accelerate adoption of lower-cost biosimilars.
Alas, that’s not what the latest data reveal.
DCI’s analysis of four national commercial insurers—Aetna, Anthem, Cigna, and UnitedHealthcare—and 26 hospitals found that:
Hospitals still earn significant markups over average sale price (ASP). 340B hospitals earn even more.
Insurers pay wildly varying amounts for the same drug.
Some hospitals get paid significantly more than others for the same drug.
Insurers can pay more for a lower-cost biosimilar than for the higher-cost reference product.
While provider-administered biosimilars are significantly cheaper than their reference products, hospitals and insurers are still making them expensive for plan sponsors. Meanwhile, patients with coinsurance and deductibles are paying higher out-of-pocket costs.
Transparency was supposed to clean things up—but someone forgot to bring the mop.
Let’s cut through the steamy summer haze with a refreshing breeze of industry insights from Drug Channels—perfect for pondering while you float in your favorite pool:
P.S. Want more real-time insights? Join my more than 64,000 LinkedIn followers for daily links to neat stuff, along with sharp and thoughtful commentary from the DCI community.
The 2025 launch of biosimilars to Johnson & Johnson’s Stelara (ustekinumab) marks another turning point in pharmacy benefit dynamics. But unlike the chaotic rollout of Humira biosimilars, pharmacy benefit managers (PBMs) came prepared.
Private label strategies, aggressive pricing, and exclusive formulary deals have transformed what might have been a slow-crawling biosimilar introduction into a full-on pricing war. As with Humira, the reality of biosimilar economics is far messier—and more revealing—than the policy narratives suggest.
In this post, I examine how the major PBMs—and some of the smaller ones—are handling Stelara biosimilars, what’s changed since the Humira experience, and why their strategies reflect the growing dominance of private-label rebating schemes.
As always, with great pricing power comes great responsibility. Excelsior!
This week, I’m rerunning some popular posts while I prepare for Friday’s live video webinar: What’s Next for Retail Pharmacy: Data, Debate, and Disruption. I’ll be joined by special guest Antonio Ciaccia, CEO of 46brooklyn Research, and President of 3 Axis Advisors.
Three’s still company in the world of pharmacy benefit managers.
For 2024, nearly 80% of all equivalent prescription claims were processed by three familiar companies: the CVS Caremark business of CVS Health, the Express Scripts business of Cigna, and the Optum Rx business of UnitedHealth Group. The names haven’t changed, but shifting relationships and contract shakeups have altered the plot, with Express Scripts stepping into a new lead role.
Below, we break down the latest market share data from Drug Channels Institute (DCI), explore the developments driving these changes, and examine what they signal for the future of the PBM landscape.
ICYMI, the largest three pharmaceutical wholesalers—Cardinal Health, Cencora, and McKesson—are using vertical integration to build significant market positions in businesses beyond drug distribution.
In the video clip below, I review the vertical integration status of the largest three pharmaceutical wholesalers, illustrated in the chart below.
[Click to Enlarge]
I also:
Explain how wholesalers have strengthened their position in buy-and-bill channels for provider-administered drugs through vertical integration with their downstream customers.
Discuss how and why private equity roll-up activity has provided wholesalers with strategic opportunities to acquire ownership stakes in practice management companies.
Outline the market access implications for provider-administered biosimilars in the buy-and-bill market.
By 
This week, I’m rerunning some popular posts while I prepare for tomorrow's live video webinar: 
This week, I’m rerunning some popular posts while I put the finishing touches on DCI’s 
This week, I’m rerunning some popular posts while I prepare for Friday’s live video webinar: 
This week, I’m rerunning some popular posts while I prepare for tomorrow’s live video webinar: 