Employer-funded PBMs and your health plan: the big three and the transparent alternatives.
Discount cards sit beside your plan. These sit inside it. A pharmacy benefit manager contracted by the employer, rather than chosen by a carrier, changes how your plan’s drug claims are priced, reported and audited. Here is what each vendor says about itself and what we would ask before switching. For the cash-price side, see our cash-price pharmacy comparison.
What an employer-funded PBM is, how it is paid, and who it suits.
Based on vendor sites and trade press as of October 2026. Terms change, so confirm before you rely on any of it. See the side-by-side PBM comparison page.
What It Is
A pharmacy benefit manager the employer contracts with directly, usually for a self-funded plan, to process the plan’s pharmacy claims. It does the same job as the largest PBMs. What differs is the pricing model and how much of the data you can see. Try our free pharmacy rebate value calculator to run the numbers for your own group.
How It Gets Paid
Per Healthcare Brew, alternative PBMs generally earn a fee for service, such as an administrative fee per member per month, instead of keeping a share of negotiated discounts. Navitus said it takes no spread and signs contracts of about three years. You can test your own figures with our PMPM claims calculator.
Who It Suits
Self-funded employers and public entities that want claim-level data and a say in formulary design. A fully insured group usually cannot pick the PBM, because the carrier does. Ask your adviser whether your funding arrangement gives you that choice before you spend time comparing vendors. You can test your own figures with our specialty drug exposure calculator.
Who is in this category.
Each vendor is described as it describes itself or as trade press reports it. MC-Rx is powered by ProCare Rx. The Big 3 are included for comparison. We have not audited any of them.
ScriptGuideRX (SGRx Health)
Describes cost-effective prescription benefit management without compromising quality or service. Its site also lists SGRXSaves savings, 340B administration, a TPA service, non-opioid support and a HealthChoice of Michigan program.
Watch for. Ask which of those services you would actually use, and which are priced separately.
Navitus
Owned by SSM Health and Costco, per Healthcare Brew. It charges an administrative fee per member per month, says it takes no spread and says it passes on 100% of savings.
Watch for. It is vertically integrated with its specialty pharmacy, Lumicera. Ask how that pharmacy is used and how it is paid.
AffirmedRx
Started in 2021 and named by Healthcare Brew among the transparent alternatives gaining traction. 7-Eleven and Purdue University were reported as clients.
Watch for. A newer vendor means a shorter track record. Ask for references with a similar plan size.
Rightway
Founded in 2017 and reported to have moved Tyson Foods away from Caremark in early 2024. It markets transparent fee models.
Watch for. Large-employer references may not match your plan size. Ask for peers.
ProCare Rx
The PBM behind MC-Rx, which describes itself as powered by ProCare Rx. MC-Rx reported in December 2024 that ProCare Rx earned full URAC reaccreditation in pharmacy benefit management.
Watch for. MC-Rx and ProCare Rx are separate brands on one platform. Ask which entity signs your contract and who answers your claims questions.
MC-Rx
A direct-source PBM, powered by ProCare Rx, with offices in Gainesville, Georgia and Caguas, Puerto Rico. It says it controls its own systems, pharmacy contracts and claims processing, and passes rebates through.
Watch for. Its figure that over 90% of PBMs lack their own pharmacy networks and claims platforms is its own 2023 claim. Ask for evidence and for current client references.
What Direct-Source Means
MC-Rx defines a direct-source PBM as one with wholly owned systems, wholly owned pharmacy contracts and a transparent rebate structure, so no step of claims processing is outsourced.
Watch for. It is a vendor-defined term, not an industry standard. Ask each PBM which functions it owns and which it outsources.
CVS Caremark
One of the Big 3, owned by CVS Health, with 18% of rebate negotiation in 2024 per the AMA’s 2026 update. In August 2026 the FTC announced a proposed settlement with Caremark that would require a standard offering passing rebates through at the point of sale and letting plan sponsors move off rebate guarantees and spread pricing, per Lockton.
Watch for. The order is proposed, and the terms apply to a standard offering. Ask what Caremark is actually offering you and how it changes the timing of rebate dollars in your budget.
Express Scripts (Evernorth)
One of the Big 3, part of Cigna’s Evernorth, with 23% of rebate negotiation in 2024 per the AMA’s 2026 update, up from 17% in 2022. It introduced a fee-based, rebate-free model in October 2025, now called Signature Pharmacy Benefit Services. Cigna Healthcare fully insured clients start in 2027, and it becomes the standard for all Evernorth pharmacy benefit clients in 2028, per Darwin Research Group.
Watch for. Evernorth owns the PBM and affiliated pharmacies. Ask how affiliated pharmacies are paid and what happens to your guarantees.
Optum Rx
One of the Big 3, part of UnitedHealth Group, with 23% of rebate negotiation in 2024 per the AMA’s 2026 update. In May 2026 it announced a fee-based model with a monthly fee per member, meant to eliminate spread pricing, to be offered to all clients by the end of 2027. Clients are not required to move right away, and its fees, including those tied to its group purchasing organization Emisar, are to be disclosed.
Watch for. A fee-based model changes how the PBM earns money. Ask for the full fee schedule and for payments from manufacturers in writing.
Prime Therapeutics
The fourth-largest PBM in the AMA’s 2026 update, with 11% of rebate negotiation in 2024. Several Blue Cross Blue Shield insurers jointly own it, and it is almost exclusively used by BCBS insurers, including some that do not own it.
Watch for. Ask which BCBS plan relationships bring you to Prime, and what you can negotiate separately.
CarelonRx
Elevance Health’s PBM, with 8% of rebate negotiation in 2024 per the AMA. It was initially used only by its owner and is still largely used by it, and it is now also used by another BCBS insurer.
Watch for. If your carrier is an Elevance plan, ask whether the PBM is bundled and whether you can carve it out.
CenterWell Pharmacy (Humana)
Humana’s PBM, with 5% of rebate negotiation in 2024 per the AMA, down from 7% in 2022. It is used exclusively by its owner. Drug Channels put Humana Pharmacy Solutions at 7% of 2025 prescription claims.
Watch for. The AMA says it serves Humana only, so it is not an option for most employers outside a Humana plan.
MedImpact
An independent PBM. The AMA lists MedImpact and SS and C Health as the only PBMs in its top 10 for retail network management and claims adjudication that are not affiliated with a health insurer. Drug Channels put MedImpact at 5% of 2025 prescription claims.
Watch for. Ask for the contract terms and client references like any other PBM. Independence does not by itself mean lower net cost.
Kaiser Pharmacy
Kaiser’s own PBM, with 8% of rebate negotiation in 2024 per the AMA, down from 9% in 2022. The AMA says it is used exclusively by Kaiser.
Watch for. It is not available to employers outside a Kaiser plan. It matters mainly as a sign of how much of the market sits inside insurers.
Scripius (Intermountain)
The PBM of Intermountain, with 1% of rebate negotiation in both 2022 and 2024 per the AMA. The AMA lists it as the ninth-largest PBM.
Watch for. It is a health-system and insurer-owned PBM. Ask whether it serves employers outside that system before you consider it.
HealthPartners
The AMA calls the tenth-largest “PBM” an integrated insurer and health system that negotiates rebates in house, with a share under 1% in 2022 and 2024.
Watch for. It is in the data as an insurer doing the work itself, not as a PBM you would hire.
SS and C Health
Named by the AMA, along with MedImpact, as one of the only two PBMs in its top 10 for retail network management and claims adjudication that are not affiliated with a health insurer. Its claims adjudication share was 1% in 2024, down from 2% in 2022.
Watch for. It is a small, independent name. Ask for the same pricing, audit and reference terms you would ask of any PBM.
How Concentrated Is the Market
The AMA’s September 2026 update found the four largest PBMs held 75% of the national market in 2024, up from 70% in 2022. The seven largest held 96% and the 10 largest 99%, and all 10 share ownership with a health insurer. In 2024, 32 PBM markets, or 94%, were highly concentrated, up from 28 (82%) in 2022.
Watch for. Concentration means fewer real choices. Ask which PBMs can actually serve your plan type and region, and whether your carrier’s PBM can be carved out.
The Big 3 Are Losing Employers
In the 2026 National Alliance of Healthcare Purchaser Coalitions survey of 408 employers, the share using a Big 3 PBM fell from 63.4% in 2025 to 54.3%. About 23% of Big 3 clients said they were not sure what was in their contracts, against 12% of clients of other PBMs.
Watch for. The Big 3 deny overcharging and say they pass most savings through. Compare their new models and the alternatives on the same claims file.
SmithRx
A transparent PBM that claims savings of 20% or more. See its page for the details.
Capital Rx
A PBM founded in 2017 and now part of Judi Health. See its page for the details.
The 10 Largest PBMs in the U.S.
Rebate-negotiation market share across commercial and Medicare Part D, from the AMA’s 2026 update using 2022 and 2024 data. Shares are rounded, so they do not sum exactly.
| Rank | PBM | Co-Owned Insurer | 2024 Share | 2022 Share |
|---|---|---|---|---|
| 1 | OptumRx | UnitedHealth | 23% | 21% |
| 2 | Express Scripts | Cigna | 23% | 17% |
| 3 | CVS Caremark | Aetna (CVS Health) | 18% | 21% |
| 4 | Prime Therapeutics | Blue Cross Blue Shield plans | 11% | 10% |
| 5 | Kaiser Pharmacy | Kaiser | 8% | 9% |
| 6 | CarelonRx | Elevance Health | 8% | 8% |
| 7 | CenterWell Pharmacy | Humana | 5% | 7% |
| 8 | Navitus | SSM Health and Dean | 1% | 1% |
| 9 | Scripius | Intermountain | 1% | 1% |
| 10 | HealthPartners | Self (in-house) | Under 1% | Under 1% |
A different measure, prescription claims processed in 2025 per Drug Channels Institute, ranks Express Scripts at 31%, CVS Caremark at 26%, Optum Rx at 23%, Humana Pharmacy Solutions at 7%, MedImpact at 5% and Prime Therapeutics at 3%. The three largest control about 80%. Source: AMA Policy Research Perspectives, September 2026; Drug Channels Institute via Becker’s.
What an employer-funded PBM does to the plan.
The employer questions come down to price, data and who you can leave.
Insurance
It replaces your PBM, not your coverage. Employees keep the same plan and the same ID card. Because coverage stays in place, the switch is mainly an administrative change, though it still deserves testing and clear communication before the effective date. Plan communications should say so plainly.
Deductible Treatment
Claims adjudicated through the plan count the way your plan design says. That is the main difference from a coupon or a cash card. Ask your administrator to show a sample claim processed both ways, so you can see how amounts are applied before you decide.
Employee Experience
Employees use their plan ID as usual. Pharmacy networks and formularies can change at the switch, so plan communication matters. Run a sample of common prescriptions through the new setup ahead of time, and tell employees early which ones are affected and who to call.
Claims Data
Claim-level data is the main selling point. Confirm the file format, how often you receive it and whether you can audit it. Ask for a sample file before you sign, and have someone check that it can be read and reconciled to the invoices you receive.
Six questions to put to any PBM.
Put the same questions to every vendor, including your current one, and compare the answers in writing.
How Are You Paid?
Ask for every revenue source in writing: administrative fees, spread, rebate retention, manufacturer fees and any pharmacy ownership. A vendor that is comfortable with full disclosure will put the answer in the contract itself, not only in a sales document. Keep the written answer for your files.
Is There Spread?
Ask whether you are billed more for a drug than the pharmacy is paid, and how that is shown on the claim. Pricing models that pass the pharmacy payment through at cost make the answer easy to see, so ask for a sample claim.
What Can We Audit?
Ask for audit rights at the claim level, and who pays for an audit if it finds a problem. Also ask how long the audit window stays open, whether the vendor can limit which claims you review, and what records it will provide, so the right is practical.
What Is the Term and the Exit?
Ask about contract length, renewal terms and what happens to your data and transition support if you leave. Get the transition steps in writing, including timelines for returning your data, so leaving later does not leave a gap in pharmacy service. Ask about any fees for early exit.
Who Owns the Specialty Pharmacy?
Ask whether specialty drugs must go through an affiliated pharmacy, and how that pharmacy is paid. Specialty drugs are costly, so the answer can affect both your spend and how quickly employees get their medication. Ask what happens if an employee prefers another pharmacy.
Who Are Your References?
Ask for clients of your size and plan type, and how the vendor measures trend. Self-reported trend can mean different things. Speak with at least one reference directly, and ask what surprised them after the first year and what they would negotiate differently.
When an employer-funded PBM fits and when to skip it.
Our view, based on published terms. It is not a recommendation for any specific vendor.
It Fits When
You are self-funded, your pharmacy spend is big enough to model, and you want claim-level data and audit rights. A competitive bid against your current PBM is worth the effort. Before bidding, gather a full year of pharmacy claims so each bidder prices the same population.
Skip It When
You are fully insured and the carrier controls the PBM, or your pharmacy spend is small enough that a switch would cost more in disruption than it saves. If you are unsure which describes you, ask your adviser to estimate the likely savings and disruption before committing.
Where to go next.
Two PBM pages and two cash-price comparisons.
Every PBM we cover, in one place.
Each program below has its own section: what it is, what it costs, where it works, how it treats the deductible, and when it fits or does not. As published in October 2026; terms change, so confirm before pointing employees to one.
SS and C Health · HealthPartners · Scripius (Intermountain) · Kaiser Pharmacy · MedImpact · CenterWell Pharmacy (Humana) · CarelonRx · Prime Therapeutics · Optum Rx · Express Scripts (Evernorth) · CVS Caremark · MC-Rx · Rightway · AffirmedRx · Navitus · ScriptGuideRX · ProCare Rx
SS and C Health and your health plan: how it works inside the plan.
SS&C Health is the health unit of SS&C Technologies. Its pharmacy offer is a platform for PBMs and plans, so it may not be something an employer buys directly. It is a PBM, not a discount card. See all 19 in the inside-the-plan comparison.
What It Is
SS&C Health’s PBM arm is DST Pharmacy Solutions, and its pharmacy offer centers on DomaniRx, which it calls a cloud-native platform for modern pharmacy benefit management.
How It Prices
We found no pricing or transparency language on its pages. It describes DomaniRx as an adaptive, scalable pharmacy benefit administration platform with modular offerings.
Where It Works
SS&C’s health page lists PBMs, commercial health plans, drug card programs, government programs and providers as customers. A blog says DST Pharmacy Solutions earned URAC PBM accreditation, but the post is undated.
Insurance
SS&C Health is usually a back-end vendor. Your employees would meet it through a plan or PBM, not as a separate benefit.
Deductible Treatment
Claims processed through the plan count the way your plan design says, unlike a cash card or coupon.
Claims Data
Ask for the file format, how often you receive it and your audit rights. Claim-level data is only useful if you can test it.
It Fits When
You want to understand the platform behind a PBM or plan you are already evaluating.
Skip It When
You are looking for an employer-facing PBM to bid directly.
Does it count toward the deductible?
Claims processed through the plan count the way your plan design says. That is different from a cash card or coupon purchase.
HealthPartners and your health plan: how it works inside the plan.
HealthPartners offers integrated pharmacy benefit management inside its group health plans. It is sold with the medical plan, not on its own. It is a PBM, not a discount card. See all 19 in the inside-the-plan comparison.
What It Is
HealthPartners’ page lists a Bloomington, Minnesota address and describes pharmacy benefit management offered inside its group health plans. Ownership is not stated on the page.
How It Prices
HealthPartners says carving pharmacy into the medical plan brings care and coverage together, with improved transparency, fuller data and more connected insights. It also says carve-outs may save near term but cost more over time. That is its own view.
Where It Works
It lists real-time flagging of duplicate medical and pharmacy therapies, site-of-care guidance, custom reporting and dedicated Midwest-based account management for employers on its group plans.
Insurance
HealthPartners pharmacy comes with the HealthPartners plan, so choosing it means choosing the medical plan.
Deductible Treatment
Claims processed through the plan count the way your plan design says, unlike a cash card or coupon.
Claims Data
Ask for the file format, how often you receive it and your audit rights. Claim-level data is only useful if you can test it.
It Fits When
You are considering HealthPartners for medical and want pharmacy and medical data in one view.
Skip It When
You want to bid pharmacy separately from medical, or your workforce is outside its service area.
Does it count toward the deductible?
Claims processed through the plan count the way your plan design says. That is different from a cash card or coupon purchase.
Scripius (Intermountain) and your health plan: how it works inside the plan.
Scripius is a nationwide PBM owned through Intermountain Health’s Select Health. It says it offers pass-through pricing and claim-level rebate data. It is a PBM, not a discount card. See all 19 in the inside-the-plan comparison.
What It Is
Select Health’s May 2021 release says Scripius is the rebrand of Select Health Prescriptions. It describes Select Health as a not-for-profit health plan and wholly owned subsidiary of Intermountain Healthcare. Becker’s (February 2025) says Select Health established the PBM in 1998.
How It Prices
Scripius’s site says it offers unrivaled transparency and a full spectrum view into contracts, pricing and data. The 2021 release says it owns its network and rebate contracts, which it says gives employers pass-through pricing and claim-level rebate information.
Where It Works
Scripius says it serves health plans and employers. The 2021 release says mainly large employers and national clients. It lists in-house retail, mail-order and specialty pharmacy, and Cost Plus Drugs access for Select Health members from September 15, 2023.
Insurance
Scripius replaces your PBM, not your coverage. Employees keep the same plan and ID card.
Deductible Treatment
Claims processed through the plan count the way your plan design says, unlike a cash card or coupon.
Claims Data
Ask for the file format, how often you receive it and your audit rights. Claim-level data is only useful if you can test it.
It Fits When
You are a self-funded employer, particularly a larger one, and want a health-system-owned PBM with pass-through terms.
Skip It When
Your employees are mostly outside Utah and Idaho and you cannot confirm network adequacy, or you are fully insured.
Does it count toward the deductible?
Claims processed through the plan count the way your plan design says. That is different from a cash card or coupon purchase.
Kaiser Pharmacy and your health plan: how it works inside the plan.
Kaiser Permanente pharmacy is delivered inside Kaiser’s integrated care and coverage model. It is not a standalone PBM you can add to another plan. It is a PBM, not a discount card. See all 19 in the inside-the-plan comparison.
What It Is
Kaiser Permanente describes an integrated pharmacy model that delivers value for employers. It serves its own members across its regions: California, Colorado, Georgia, Hawaii, Maryland, Virginia and Washington DC, Oregon, and Washington.
How It Prices
A May 2026 Kaiser Permanente release quotes its Washington regional president crediting a purchasing model that cuts out intermediaries.
Where It Works
Pharmacy is part of the Kaiser plan, so it requires adopting the Kaiser care and coverage model in a Kaiser region.
Insurance
Kaiser pharmacy comes with the Kaiser plan. You cannot keep another carrier’s plan and add it as a PBM.
Deductible Treatment
Claims processed through the plan count the way your plan design says, unlike a cash card or coupon.
Claims Data
Ask for the file format, how often you receive it and your audit rights. Claim-level data is only useful if you can test it.
It Fits When
Your workforce is concentrated in Kaiser regions and you are considering a Kaiser plan for medical.
Skip It When
You have employees outside Kaiser regions, or you want to change the PBM without changing the medical plan.
Does it count toward the deductible?
Claims processed through the plan count the way your plan design says. That is different from a cash card or coupon purchase.
MedImpact and your health plan: how it works inside the plan.
MedImpact is a PBM that calls itself the largest independent PBM. Independent speaks to ownership, not to a pricing model. It is a PBM, not a discount card. See all 19 in the inside-the-plan comparison.
What It Is
MedImpact’s press release calls it the largest independent PBM and cites NCQA accreditation. Its site shows URAC PBM accreditation. We could not confirm its ownership details or headquarters at a source.
How It Prices
MedImpact’s homepage makes no pricing or transparency claims. Get your pricing terms, rebate handling and audit rights in writing.
Where It Works
It says it serves many of the nation’s health plans and self-insured employers and 55 million consumers globally. Its solutions include home delivery, specialty and government programs. The FTC named MedImpact among six PBMs in its 2022 orders.
Insurance
MedImpact runs the pharmacy benefit inside your plan. Employees keep the same plan and ID card.
Deductible Treatment
Claims processed through the plan count the way your plan design says, unlike a cash card or coupon.
Claims Data
Ask for the file format, how often you receive it and your audit rights. Claim-level data is only useful if you can test it.
It Fits When
You are self-funded, you want a PBM that is not owned by a carrier or retailer, and you will bid it on net cost.
Skip It When
You need a PBM that publishes its pricing model, or you are fully insured and the carrier controls the PBM.
Does it count toward the deductible?
Claims processed through the plan count the way your plan design says. That is different from a cash card or coupon purchase.
CenterWell Pharmacy (Humana) and your health plan: how it works inside the plan.
CenterWell Pharmacy is Humana’s pharmacy business. Its employer offering is new and runs through a partnership with Cost Plus Drugs. It is a PBM, not a discount card. See all 19 in the inside-the-plan comparison.
What It Is
CenterWell’s site says it is still part of the Humana family, and it was formerly Humana Pharmacy. It runs mail-order and specialty pharmacy, mostly for Medicare members.
How It Prices
CenterWell states no pricing model. Fierce Healthcare attributes a 15% cost-plus pass-through pricing approach to Cost Plus Drugs, not to CenterWell.
Where It Works
Fierce Healthcare reported on April 27, 2026 that CenterWell was named an official pharmacy partner of Cost Plus Drugs for employer prescription solutions. The FTC named Humana Pharmacy Solutions among six PBMs in its 2022 orders.
Insurance
CenterWell can sit beside or inside your plan depending on the arrangement. Confirm whether you are buying a full PBM or a pharmacy partner.
Deductible Treatment
Claims processed through the plan count the way your plan design says, unlike a cash card or coupon.
Claims Data
Ask for the file format, how often you receive it and your audit rights. Claim-level data is only useful if you can test it.
It Fits When
You already have a PBM and want to add a pharmacy partner with employer-facing pricing.
Skip It When
You need a full PBM with its own formulary, claims and rebate management, or you want a long employer track record.
Does it count toward the deductible?
Claims processed through the plan count the way your plan design says. That is different from a cash card or coupon purchase.
CarelonRx and your health plan: how it works inside the plan.
CarelonRx is the pharmacy benefit manager of Elevance Health. Elevance’s own filing says it delegates some core pharmacy services to CVS Caremark. It is a PBM, not a discount card. See all 19 in the inside-the-plan comparison.
What It Is
Elevance Health’s site calls CarelonRx “our pharmacy benefit manager.” CarelonRx’s own page says it serves members, providers, employers, plan sponsors, consultants and brokers.
How It Prices
The CarelonRx homepage states no pricing model. Elevance’s FY2025 10-K says CarelonRx pricing is presented to market as discounts off average wholesale price and uses rebate projections.
Where It Works
CarelonRx says it provides home delivery pharmacy, prior-authorization and prescribing tools, and integrated medical and pharmacy benefits. Fierce Healthcare reported a specialty savings tool for employers.
Insurance
CarelonRx runs the pharmacy benefit inside your plan. For Elevance medical groups the PBM is usually chosen with the carrier.
Deductible Treatment
Claims processed through the plan count the way your plan design says, unlike a cash card or coupon.
Claims Data
Ask for the file format, how often you receive it and your audit rights. Claim-level data is only useful if you can test it.
It Fits When
You use Elevance for medical and want to understand how the pharmacy benefit is priced and reported separately.
Skip It When
You want a PBM chosen independently of your carrier.
Does it count toward the deductible?
Claims processed through the plan count the way your plan design says. That is different from a cash card or coupon purchase.
Prime Therapeutics and your health plan: how it works inside the plan.
Prime Therapeutics is a PBM that describes itself as created by not-for-profit Blue Cross and Blue Shield plans. Access often runs through a Blue plan. It is a PBM, not a discount card. See all 19 in the inside-the-plan comparison.
What It Is
Prime describes itself as created by not-for-profit Blue Cross and Blue Shield plans and formed in 1998. Its older overview says it was designed by health plans for health plans.
How It Prices
Prime calls itself a truly transparent pharmacy solutions partner. Bloomberg (October 2026, reposted on Prime’s site) reports Prime aims to shift to upfront drug pricing and away from a rebate-based system. We did not verify the mechanics.
Where It Works
Prime says it also serves employers, consultants, government programs and unions. The FTC named Prime as one of six PBMs receiving its 2022 orders for the PBM study.
Insurance
Prime runs the pharmacy benefit inside your plan. For many employers it is the PBM behind a Blue plan, so the choice is made with the carrier.
Deductible Treatment
Claims processed through the plan count the way your plan design says, unlike a cash card or coupon.
Claims Data
Ask for the file format, how often you receive it and your audit rights. Claim-level data is only useful if you can test it.
It Fits When
You are on or considering a Blue plan and want to understand the PBM behind it before renewal.
Skip It When
You want to choose a PBM independently of your carrier.
Does it count toward the deductible?
Claims processed through the plan count the way your plan design says. That is different from a cash card or coupon purchase.
Optum Rx and your health plan: how it works inside the plan.
Optum Rx is the pharmacy care business of Optum, part of UnitedHealth Group. It is one of the three largest PBMs and has announced a fee-based model. It is a PBM, not a discount card. See all 19 in the inside-the-plan comparison.
What It Is
Optum Rx is part of UnitedHealth Group. The FTC staff report says the three largest PBMs manage 79% of U.S. prescription claims. Optum Rx says it serves clients and nearly 61 million people.
How It Prices
A May 11, 2026 UnitedHealth Group release announced a fee-based model for every PBM customer, with monthly defined per-member fees independent of list prices or volume, which it says eliminates spread pricing. It says fees tied to its group purchasing organization are disclosed and move to flat service fees by the end of 2027, and that it committed to pass through 100% of manufacturer rebates by January 1, 2028.
Where It Works
Optum Rx says its network includes more than 67,000 community pharmacies, plus home delivery, specialty and infusion services.
Insurance
Optum Rx runs the pharmacy benefit inside your plan. Employees keep the same plan and ID card.
Deductible Treatment
Claims processed through the plan count the way your plan design says, unlike a cash card or coupon.
Claims Data
Ask for the file format, how often you receive it and your audit rights. Claim-level data is only useful if you can test it.
It Fits When
You are self-funded, you want national scale, and you will compare the fee-based model against other options on net cost.
Skip It When
You need independence from an insurer-owned PBM, or the phase-in dates are not in your contract.
Does it count toward the deductible?
Claims processed through the plan count the way your plan design says. That is different from a cash card or coupon purchase.
Express Scripts (Evernorth) and your health plan: how it works inside the plan.
Express Scripts is the PBM run by Evernorth, the health services division of The Cigna Group. It is one of the three largest PBMs. It is a PBM, not a discount card. See all 19 in the inside-the-plan comparison.
What It Is
Express Scripts is part of Evernorth Health Services, which also includes Accredo, eviCore and MDLIVE. The FTC staff report says the three largest PBMs manage 79% of U.S. prescription claims.
How It Prices
Evernorth announced a rebate-free pharmacy benefit model in which negotiated discounts are available up front at the counter. Per its release, Cigna Healthcare adopts it for fully insured lives in 2027, and it becomes the standard for all Evernorth PBM clients in 2028. It also says it pays pharmacies cost plus a dispensing fee from 2026.
Where It Works
Evernorth says it serves businesses and other health plans. Its services include Express Scripts Pharmacy for home delivery and Accredo for specialty drugs.
Insurance
Express Scripts runs the pharmacy benefit inside your plan. Employees keep the same plan and ID card.
Deductible Treatment
Claims processed through the plan count the way your plan design says, unlike a cash card or coupon.
Claims Data
Ask for the file format, how often you receive it and your audit rights. Claim-level data is only useful if you can test it.
It Fits When
You are self-funded, you want national scale, and you will model the rebate-free approach against your current terms.
Skip It When
You need independence from a PBM tied to a carrier parent, or the phase-in dates do not match your plan year.
Does it count toward the deductible?
Claims processed through the plan count the way your plan design says. That is different from a cash card or coupon purchase.
CVS Caremark and your health plan: how it works inside the plan.
CVS Caremark is the pharmacy benefit manager of CVS Health. It is one of the three largest PBMs and says it is changing how it prices. It is a PBM, not a discount card. See all 19 in the inside-the-plan comparison.
What It Is
CVS Caremark is CVS Health’s PBM. The FTC staff report says the three largest PBMs, CVS Caremark, Express Scripts and Optum Rx, manage 79% of U.S. prescription claims.
How It Prices
Caremark says it introduced TrueCost in 2023 as the market’s first transparent pricing model, with acquisition-cost-based pricing and drug-level rebate visibility. It says a 2026 FTC settlement leads to a new standard offering that eliminates spread pricing: the plan pays pharmacy acquisition cost plus a defined administrative fee.
Where It Works
Caremark says it serves employers, health plans, unions and government organizations. It cites its own analytics showing TrueCost cut large price changes by 44% and generic price variability by 55%.
Insurance
Caremark runs the pharmacy benefit inside your plan. Employees keep the same plan and ID card.
Deductible Treatment
Claims processed through the plan count the way your plan design says, unlike a cash card or coupon.
Claims Data
Ask for the file format, how often you receive it and your audit rights. Claim-level data is only useful if you can test it.
It Fits When
You are self-funded and large enough to negotiate, you want national scale, and you will compare Caremark’s new model against the alternatives.
Skip It When
You need independence from a pharmacy-owning parent, or you cannot get the new pricing terms in writing.
Does it count toward the deductible?
Claims processed through the plan count the way your plan design says. That is different from a cash card or coupon purchase.
MC-Rx and your health plan: how it works inside the plan.
MC-Rx is a full-service PBM that describes itself as a Direct Source PBM powered by ProCare Rx, with a full transparency model. It is a PBM, not a discount card. See all 19 in the inside-the-plan comparison.
What It Is
MC-Rx calls itself a national, URAC-accredited PBM. ProCare Rx’s April 2022 release says ProCare acquired MC-21 in 2018 and the two were rebranded “MC-Rx Powered by ProCare Rx.” MC-Rx is in Gainesville, Georgia, with a Puerto Rico office.
How It Prices
MC-Rx says it has had a full transparency model since inception, and ProCare Rx says it offers clear rebate structures, defined service fees and net cost reporting. We found no specific pricing terms.
Where It Works
It lists employer groups, TPAs, unions, health plans, Medicare and Medicaid, hospice, workers’ compensation and 340B programs, and says it serves clients in all 50 states and Puerto Rico.
Insurance
MC-Rx replaces your PBM, not your coverage. Employees keep the same plan and ID card.
Deductible Treatment
Claims processed through the plan count the way your plan design says, unlike a cash card or coupon.
Claims Data
Ask for the file format, how often you receive it and your audit rights. Claim-level data is only useful if you can test it.
It Fits When
You are self-funded, you want a direct-source PBM, and you will compare net cost against your current PBM.
Skip It When
You are fully insured and the carrier controls the PBM, or you need a broad rebate-leverage comparison before deciding.
Does it count toward the deductible?
Claims processed through the plan count the way your plan design says. That is different from a cash card or coupon purchase.
Rightway and your health plan: how it works inside the plan.
Rightway is a venture-backed care navigation company with a PBM. It says it charges a single transparent fee and passes through 100% of rebates. It is a PBM, not a discount card. See all 19 in the inside-the-plan comparison.
What It Is
Rightway was founded in 2017, per MobiHealthNews (September 2026). Its PBM is paired with care navigation, including a pharmacist team, a member app and a client reporting portal.
How It Prices
Rightway says its revenue comes from a single transparent administrative fee, with 100% rebate pass-through, no spread and none of the supply chain owned. Its SureSpend guarantee sets a pharmacy cost ceiling, and Rightway says it refunds 100% of any overage.
Where It Works
It markets to employers, including large employers, and says it works alongside TPAs. MobiHealthNews and HLTH reported a $155M Series E in September 2026 led by Francisco Partners.
Insurance
Rightway replaces your PBM, not your coverage. Employees keep the same plan and ID card, with added navigation services.
Deductible Treatment
Claims processed through the plan count the way your plan design says, unlike a cash card or coupon.
Claims Data
Ask for the file format, how often you receive it and your audit rights. Claim-level data is only useful if you can test it.
It Fits When
You are self-funded, you want a guarantee and a navigation service in one contract, and you will model it against your current PBM.
Skip It When
You want a PBM with no navigation layer, or you are fully insured and the carrier controls the PBM.
Does it count toward the deductible?
Claims processed through the plan count the way your plan design says. That is different from a cash card or coupon purchase.
AffirmedRx and your health plan: how it works inside the plan.
AffirmedRx is a PBM organized as a public benefit corporation. It says it does not engage in spread pricing and serves self-funded employers. It is a PBM, not a discount card. See all 19 in the inside-the-plan comparison.
What It Is
AffirmedRx, PBC, calls itself a public benefit corporation PBM. Its press release is datelined Louisville, Kentucky. We could not confirm its founding year at a source.
How It Prices
AffirmedRx says it never engages in spread pricing, passes through all manufacturer price concessions and gives claim-level data transparency. It says plan sponsors have the final say on formulary. The fee structure is not stated on the pages we read.
Where It Works
It says its network has more than 67,000 pharmacies and that it publishes its formulary. International Business Times interviewed its CEO in October 2025. In August 2026 it announced a No. 5 ranking on the 2026 Inc. 5000, which is a company-issued claim.
Insurance
AffirmedRx replaces your PBM, not your coverage. Employees keep the same plan and ID card.
Deductible Treatment
Claims processed through the plan count the way your plan design says, unlike a cash card or coupon.
Claims Data
Ask for the file format, how often you receive it and your audit rights. Claim-level data is only useful if you can test it.
It Fits When
You are self-funded and want a newer, transparency-focused PBM, and you will ask for references at a plan size like yours.
Skip It When
You need a long track record, or you are fully insured and the carrier controls the PBM.
Does it count toward the deductible?
Claims processed through the plan count the way your plan design says. That is different from a cash card or coupon purchase.
ScriptGuideRX and your health plan: a PBM with a Michigan HealthChoice program.
ScriptGuideRX, which trades as SGRx Health, describes cost-effective prescription benefit management without compromising quality or service. Its site also lists a savings program, 340B administration, a TPA service and a HealthChoice of Michigan program. Here is what that means for an employer plan. It is one of several options in our guide to employer-funded PBMs.
What It Is
A pharmacy benefit management company. Its site lists pharmacy services, prescriber services, drug assistance programs, Medicaid programs, SGRXSaves savings, 340B administration, non-opioid support and a TPA service.
What It Costs
Priced under a contract. SGRx does not publish pricing on its site, so ask for the fee schedule, rebate treatment and what is priced separately from the core PBM service. Compare it against at least one competing proposal, using the same claim sample for each.
Where It Works
Inside the plan for PBM services. Members have a member login, and its site also describes a Wayne County Health Choice senior prescription savings program and a HealthChoice program.
Insurance
As a PBM it replaces your current PBM, not your coverage. Employees keep their plan and ID card.
Deductible Treatment
Claims processed through the plan follow your plan design. SGRXSaves is a savings program, so ask whether purchases through it count.
Claims Data
Ask for claim-level data, reporting frequency and audit rights, as you would of any PBM.
It Fits When
You want a PBM with a Michigan connection and a range of programs, and you will bid it against your current PBM on the same claims file.
Skip It When
You are fully insured and the carrier controls the PBM, or you do not need services beyond a standard PBM contract.
Does it count toward the deductible?
Plan claims follow your plan design. Ask about SGRXSaves separately.
ProCare Rx and your health plan: how it works inside the plan.
ProCare Rx is a PBM and technology-services firm that says it offers an auditable, pass-through model. It also sits behind other brands. It is a PBM, not a discount card. See all 20 in the inside-the-plan comparison.
What It Is
ProCare Rx’s site says it has been in business more than 38 years. It lists affiliates including ProCare Rx PharmacyCare and MC-Rx. We could not confirm its ownership or headquarters at a source. It describes itself as a Direct Source PBM that lowers costs through creative formularies and hands-on member care. Its site also links Workers’ Comp / Auto and TPA Solutions pages, so confirm which lines apply to an employer health plan.
How It Prices
ProCare Rx says it has no hidden markups, fully auditable fees, no spread pricing and a pass-through model. Its ClearSight platform provides claim-level data. Fee levels are not stated on its site.
Where It Works
It describes itself as built for plan sponsors and also offers technology and services to other organizations, including white-label “powered by ProCare Rx” arrangements. Its site lists URAC PBM and specialty accreditations and SOC 1 and SOC 2 reports.
Insurance
ProCare Rx replaces your PBM, not your coverage. Employees keep the same plan and ID card.
Deductible Treatment
Claims processed through the plan count the way your plan design says, unlike a cash card or coupon.
Claims Data
Ask for the file format, how often you receive it and your audit rights. Claim-level data is only useful if you can test it.
It Fits When
You are self-funded, you want claim-level data from a pass-through PBM, and you will bid it against your current PBM.
Skip It When
You are fully insured and the carrier controls the PBM, or you cannot get a sample claim-level invoice and rebate flow.
Does it count toward the deductible?
Claims processed through the plan count the way your plan design says. That is different from a cash card or coupon purchase.
Questions about employer-funded PBMs.
Short answers for HR leaders and employers.
What does employer-funded mean here?
The employer contracts with the PBM directly, usually for a self-funded plan, instead of using the one a carrier selects.
Is ProCare Rx a discount card?
No. ProCare Rx describes itself as a PBM that administers pharmacy benefits for plans.
Can a fully insured group use one?
Usually the carrier chooses the PBM. Ask us how your carrier handles pharmacy benefits.
Is transparent the same as cheaper?
Not automatically. Transparency lets you see the price. You still have to compare net cost on your own claims.
How do we compare vendors?
Send the same claims file and drug list to each, and compare net cost, fees, rebates and guarantees side by side.
How long does a switch take?
It depends on your contract and plan year. Ask us to map the timing before you give notice to your current PBM.
Ready? Send us your renewal and we will review it with you.
The rules in one place.
ERISA For Employer Health Plans
Plan documents, fiduciary duties, claims and the litigation climate.
Transparency And Pharmacy Rules
Gag clauses, PBM contracts and disclosures, in one place.
Send us your renewal.
We’ll tell you whether it looks competitive, where we see opportunity, and the five questions we’d put to your carrier. No cost, and no obligation to move anything.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents — two more if your group is 50 or more. Nothing else; every extra one is a reason to postpone.
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