Smaller Employers Are Still Getting Left Behind on PBM Reform
While recent PBM reforms are a good first step, employers are still leaving the Big Three PBMs. It’s clear that employers are looking for the next round of reform to close the gap when it comes to rebate opacity, vertical integration and contract confusion.
Consider some stats. Employers contracting with the Big Three PBMs fell from 63.4% in 2025 to 54.3% in 2026, driven largely by employers with fewer than 1,000 employees, according to the National Alliance's Pulse of the Purchaser survey. Among current Big Three clients, 55.7% said they are considering a PBM change within the next one to three years.
A change in vendor, however, does not guarantee a change in outcomes and may not mean that employees are getting the best deal at the pharmacy counter. As HRD America reports, Raechele McMahan of Prescryptive Health put it plainly:
"A PBM can say they're going to disclose a rebate. That doesn't necessarily mean you have a choice or control to change that process."
Smaller employers are especially exposed, McMahan explains: "Just because a drug manufacturer is paying, let's say, a 50 percent rebate, it doesn't mean that those sub-10,000 group employers are getting the benefit of that 50 percent rebate."
A lack of employer understanding of PBM contracts also persists – nearly one in four Big Three clients (23.4%) answering "not sure" when asked what is in their contracts, marking an urgent need for more transparency so employers can make evidence based decisions. Vertical integration of insurers is making the process more obscure by consolidating PBMs, health insurers and specialty pharmacies under a single corporate parent that now dominates the prescription drug market, effectively putting the full drug supply chain under one roof, from coverage decisions to the pharmacy counter.
The stakes are high:
92% of employers say healthcare costs hurt competitiveness
83% say cost increases trade off with wage and salary increases
93% expect costs to shift to employees
Initial PBM reform has opened a door. The gap between what the law now requires and what employers can act on is where the next round of PBM and vertically integrated health insurer reform needs to focus.
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