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The US Pharmacy Benefit Management (PBM) Industry Report: 2013 Edition

Published By :

Koncept Analytics

Published Date : Feb 2014

Category :


No. of Pages : 59

In the US, a third party administrator of prescription drug program is known as a Pharmacy Benefit Manager (PBM). The primary responsibilities of a PBM include processing and paying prescriptions drug claim, developing and maintaining formulary, negotiating discounts and rebates with drug manufacturers and pharmacies. The US prescription volume has witnessed an unprecedented growth over the past few years and the same pattern is likely to continue in the near future. Therefore, through rebates from pharmaceutical manufacturers, price discounts from retails, and effective mail service pharmacies, the PBMs ceaselessly focus on enabling the plan sponsors and individuals to obtain prescribed drugs at lower prices.

In order to improve the value of drug benefit and manage the cost and utilization of prescribed drugs, PBMs offer a wide range of tools and techniques. These techniques include pharmacy network, plan design, electronic prescribing, manufacturer discounts, and clinical management. The US PBM industry is highly fragmented with about 100 major companies operating in the marketplace, out of which some are independently owned and operated while others are subsidiaries of major chain drug store, retail outlets and, managed care plans.

The key factors driving growth of PBM industry include accelerating US aging population, prevalence of chronic disease, increased life expectancy, healthcare reforms and increasing healthcare expenditure. Some of the noteworthy trends and developments of this industry include rising Medicare enrollment, generic drug utilization, increased acceptance of specialty drugs and ongoing merger & acquisition activities.

The report contains a comprehensive analysis of the PBM industry in the US. After the acquisition of Medco Health Solution by Express Script, an intense competition is noted among few major players; Express Script, CVS Caremark and Catamaran. The fierce competition prevailing in the US PBM industry has been studied on a number of parameters such as market share, prescription volume, revenues, claims, and operational statistics, apart from others. The company profiles of leading players in the market are also presented in the report.
Table of Content

1. Overview
1.1 History of PBM
1.2 PBM Managers
1.3 Retail Dispensing Process & Flow of Funds
1.4 Mail Dispensing Process and Flow of Funds

2. The US PBM Market Size
2.1 PBM Market by Value
  • Market Value Growth
  • Breakdown by Dispensing Channels
2.1.1 Retail Channels
2.1.2 Institutional Channels
2.2 PBM Market by Volume
  • Market Volume Growth
  • Breakdown by Dispensing Channels
2.2.1 Retail Channels
2.2.2 Institutional Channels
2.3 Generic Drugs
  • Market Overview
  • Penetration Rate
2.4 Specialty Drugs

3. Market Dynamics
3.1 Growth Drivers
3.1.1 Accelerating US Aging Population
3.1.2 Rising Incidences of Chronic and Infectious Diseases
3.1.3 Increasing Life Expectancy Rate in the US
3.1.4 Escalating Healthcare Expenditure in the US
3.1.5 Healthcare Reforms
3.1.6 Rising Pharmaceutical Sales
3.1.7 Ameliorating Economic Conditions
3.2 Trends and Developments
3.2.1 Rising Medicare Enrollments
3.2.2 Trends in Drug Prices
3.2.3 Generic Drug Utilization
3.2.4 Increased Acceptance of Specialty Drug
3.2.5 Medicaid Pharmacy Program Savings
3.2.6 Penetration of Unbranded Generic Drug Prescription
3.2.7 PBM Mergers and Acquisitions

4. Competitive Landscape
4.1 Competition by Prescription Volume
4.2 Competition by Claims
4.3 Competition by Lives Managed
4.4 Competition by Specialty Pharmacy Drug Spending
4.5 Competition by Health Plans
4.6 Analysis of PBMs Operating Statistics
4.7 Competition by Customer Segment Mix

5. Company Profiles
5.1 Express Script
5.1.1 Business Overview
5.1.2 Financial Overview
5.1.3 Business Strategies
  • Expansion through Acquisitions
  • Unremitting Focus on Innovation
5.2 CVS Caremark
5.2.1 Business Overview
5.2.2 Financial Overview
5.2.3 Business Strategies
  • Acquisitions and Collaborations
  • Focus on Geographic Expansion
5.3 Catamaran
5.3.1 Business Overview
5.3.2 Financial Overview
5.3.3 Business Strategies
  • Expansion of Customer Base
  • Broadening Services Portfolio

List of Table

The US Dollar Spend by Retail Channels - In US$ Billions (2008-2012) 
The US Dollar Spend by Institutional Channels - In US$ Billions (2008-2012) 
Number of Prescription Dispensed via Retail Channels in the US - In Million (2008-2012) 
Potential Medicaid Pharmacy Program Savings for Top 10 States (2012-2021) 
Selected PBM M&A Transactions - in US$ million (1993–2012) 
EBITDA Multiples for Selected PBM transactions (2000-2012) 
Dollar Share of Leading PBMs by PBM Revenue (2013E) 
PBM Market Share Based on Adjusted Prescription Volume (2012) 
Adjusted Mail-Order Penetration (Q112-Q213) 
Generic Dispensing Rate (Q112-Q213) 
Revenue per Adjusted Rx (Q112-Q213) 
EBITDA per Adjusted Rx (Q112-Q213) 
PBM Profitability Metrics (2012) 

List of Chart

History of PBMs
Types of PBM Services
PBM Managers Formulary Structure
Retail Dispensing Process and Flow of Funds
Mail Dispensing Process and Flow of Funds
The US Prescription Drug Market – by Value (2008-2012) 
The US Prescription Drug Market by Dispensing Channels – by Value (2012) 
Percentage Share of the Dispensing Channels in the US Prescription Drug Market - by Value (2012) 
Percentage Share of Retail Dispensing Channels in the US Prescription Drug Market – by Value (2012) 
Percentage Share of Institutional Dispensing Channels in the US Prescription Drug Market – by Value (2012) 
The US Prescription Drug Market – by Volume (2012) 
The US Prescription Drug Market by Dispensing Channels – by Volume (2012) 
Percentage Share of the Dispensing Channels in the US Prescription Drug Market - by Volume (2012) 
Percentage Share of Retail Dispensing Channels in the US Prescription Drug Market – by Volume (2012) 
Number of Prescription Dispensed via Institutional Channels in the US (2008-2012) 
Penetration of Generic Drugs (2003-2013E) 
Estimated PBM Profitability of Generic versus Branded Scripts by Channel (2012) 
Estimated Brand Revenue Lost to Generic Launches (2012-2016E) 
Specialty Market Share by Dispensing Channels (2012) 
The US Aging Population (2008-2012) 
The US Life Expectancy Rate (2006-2013E) 
The US Healthcare Expenditure per Capita (2006-2012E) 
The US Pharmaceutical Sales (2010-2012) 
GNI of the US (2006-2012) 
Medicare Enrollments (2005-2014E) 
Drugs Price Index (2008-2013E) 
Specialty Drug Spending Trend (2012 & 2015E) 
Generic Drug Penetration Rate (2005-2013E) 
Percentage Share of Leading PBMs by PBM Revenue (2013E) 
Fortune 100 PBM Market Share (2012) 
Percentage Share of PBM on Adjusted Prescription Dispensed - Volume (2012) 
PBM Market Share by Claims (2014E) 
PBM Market Share by Lives Managed (2013E) 
Percentage Share of Specialty Pharmacy Drug Spending (2012) 
Top 35 Health Plan (Based on Lives) PBM Market Share (2012) 
PBMs Pro-forma Customer Segment Mix (2012) 
Revenue of Express Script by Business Segment (2012) 
Express Script Revenue and Net Income (2008-2012) 
CVS Caremark Business Revenue – by Segment (2012) 
CVS Caremark Revenue and Net Income (2008-2012) 
Catamaran’s Revenue by Business Segment (2012) 
Catamaran Revenue and Net Income (2008-2012) 

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