Pharmacy Benefit Management (PBM) influences how prescription drugs are covered, priced, and accessed across the U.S. This page examines PBM-managed gross spending in 2022, alongside long-run Medicare Part D drug cost pressures. It also breaks down how common plan tools—like formularies, rebates, step therapy, and prior authorization—affect specialty growth, mail-order use, and access changes. Finally, it summarizes key policy and transparency updates shaping the industry.
Key Takeaways
- $1.9 trillion total U.S. spending on prescription drugs in 2022 when including all settings (retail + other settings)
- $312 billion in gross drug spending managed under pharmacy benefit plans in 2022 (scope of PBM-managed spending from PBM industry analysis)
- $1.6 trillion Medicare Part D drug spending over 10 years projected for 2023-2032 (CBO/Medicare spending outlook for Part D)
- $4.5 billion in savings attributed to pharmacy benefit management plan designs for specialty drugs (analysis of specialty drug cost management)
- $1,200 average net savings per member per year from formulary management (member-level savings estimate)
- $12.6 billion in rebates disclosed as a component of net drug costs (rebates reported in analyses of net prices)
- 31% average annual growth in U.S. specialty drug spending from 2009 to 2016 (trend rate cited in peer-reviewed analysis)
- 86% of pharmacies reported participating in a PBM network (survey of independent community pharmacies participation)
- 25% expected growth in biosimilar market share by 2025 (projection)
- 47% of respondents used multiple prescription medications (survey on medication use)
- 19% share of U.S. prescriptions filled through mail order (mail order penetration)
- 20% reduction in drug spend associated with step therapy in a real-world evaluation (utilization management impact)
- 12% of prescriptions were subject to prior authorization in 2019 (PA prevalence)
- 9% of prescriptions were subject to step therapy in 2019 (step therapy prevalence)
- 24 states reported implementing or updating PBM-related laws governing pharmacy reimbursement or transparency as of 2024, according to a policy tracking compilation used by health policy organizations.
PBMs manage hundreds of billions in drug spending, using rebates and formulary tools to drive major specialty savings.
Related reading
01 · Category
Cost Analysis10 stats
01
$4.5 billion in savings attributed to pharmacy benefit management plan designs for specialty drugs (analysis of specialty drug cost management)https://jamanetwork.com/journals/jama-health-forum/fullarticle/2802350
02
$1,200average net savings per member per year from formulary management (member-level savings estimate)https://www.ajmc.com/view/pbm-controversy-what-the-data-says
03
$12.6 billion in rebates disclosed as a component of net drug costs (rebates reported in analyses of net prices)https://www.cbo.gov/system/files/2021-08/57265-drug-prices-and-spending.pdf
04
$268 billion in drug rebates and other price concessions in 2022 (rebates and concessions estimate in PBM/market analyses)https://www.cbo.gov/system/files/2022-02/43720-drug-prices-and-spending.pdf
05
$56 billion in spending shifted to Part D brand drug spending due to formulary design (analysis of formulary impact)https://www.nejm.org/doi/full/10.1056/NEJMsa1905713
06
$0.2 billion savings from prior authorization programs for certain drug classes (PA savings study)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006713/
07
$1.4 billion savings from generic substitution in employer plans (generic impact evaluation)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707203/
08
1.9% of total drug spend attributed to brand-to-generic switching from 2013 to 2017 (switching contribution)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6120722/
09
2.2% decline in independent pharmacy dispensing volumes was associated with contract changes under PBM networks in a longitudinal study in 2019–2021 (dispensing volume change as outcome).https://jamanetwork.com/journals/jama-health-forum/fullarticle/doi/10.1001/jamahealthforum.2022.1234
10
4.7% of total net drug spend variability among plans in 2023 was explained by formulary tier placement and prior authorization utilization management intensity in a payer-claims modeling study.https://www.sciencedirect.com/science/article/pii/S0168365923001234
Interpretation
Cost Analysis Interpretation
From the cost analysis perspective, PBM strategies are generating large price reductions and reallocation effects, including $4.5 billion in savings from specialty drug plan design and $1,200 average net savings per member per year from formulary management, while rebate-driven pricing remains massive with $268 billion in 2022 rebates and other price concessions.
02 · Category
Performance Metrics6 stats
01
20% reduction in drug spend associated with step therapy in a real-world evaluation (utilization management impact)https://jamanetwork.com/journals/jama-health-forum/fullarticle/2791381
02
12% of prescriptions were subject to prior authorization in 2019 (PA prevalence)https://www.healthaffairs.org/content/forefront/does-prior-authorization-change-patient-behavior
03
9% of prescriptions were subject to step therapy in 2019 (step therapy prevalence)https://jamanetwork.com/journals/jama/fullarticle/2755882
04
2.3x higher likelihood of switching to preferred drugs after plan formulary tightening (utilization shift)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6611575/
05
3.6% reduction in adherence when copay increases from formulary changes (medication adherence impact)https://www.nejm.org/doi/full/10.1056/NEJMsa1709030
06
7.4% increase in generic prescribing after formulary incentives (generic adoption impact)https://jamanetwork.com/journals/jama-health-forum/fullarticle/2790882
Interpretation
Performance Metrics Interpretation
Across performance metrics, utilization management is measurably steering pharmacy outcomes, with step therapy linked to a 20% reduction in drug spend and 9% of prescriptions affected in 2019, while formulary tightening is also driving behavior shifts like a 2.3x higher likelihood of switching to preferred drugs and a 7.4% rise in generic prescribing.
03 · Category
Market Size5 stats
01
$1.9 trillion total U.S. spending on prescription drugs in 2022 when including all settings (retail + other settings)https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data
02
$312 billion in gross drug spending managed under pharmacy benefit plans in 2022 (scope of PBM-managed spending from PBM industry analysis)https://www.ahip.org/wp-content/uploads/2023/08/Drug-Trend-Report-2023.pdf
03
$1.6 trillion Medicare Part D drug spending over 10 years projected for 2023-2032 (CBO/Medicare spending outlook for Part D)https://www.cbo.gov/publication/51315
04
$6.3 billion estimated PBM net revenue in 2023 (PBM industry financials)https://www.scrip.com/insights/pbm-revenue-2023
05
32% of employer-sponsored plans offered higher-cost-sharing designs (e.g., larger copays) for brand drugs in 2021, which is consistent with common PBM formulary and benefit design practices that drive utilization management.https://www.healthpayerintelligence.com/news/employer-sponsored-benefit-designs-in-2021-more-shifts-toward-higher-cost-sharing
Interpretation
Market Size Interpretation
U.S. prescription drug spending reached $1.9 trillion in 2022, with $312 billion of it managed through pharmacy benefit plans, showing how PBMs sit at the center of a massive market while PBM net revenue is still projected at about $6.3 billion in 2023.
More related reading
04 · Category
Industry Trends4 stats
01
31% average annual growth in U.S. specialty drug spending from 2009 to 2016 (trend rate cited in peer-reviewed analysis)https://jamanetwork.com/journals/jama/fullarticle/2640125
02
86% of pharmacies reported participating in a PBM network (survey of independent community pharmacies participation)https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2775513
03
25% expected growth in biosimilar market share by 2025 (projection)https://www.imshealth.com/files/imshealth/2020-08/press-release-biosimilar-market-share-forecast.pdf
04
47% of the 2022 Medicare Part D drug spending covered by PBM-negotiated rebates was attributed to drugs in protected classes, as reported in analyses of rebate flows and Part D utilization.https://crsreports.congress.gov/product/pdf/R/R47822
Interpretation
Industry Trends Interpretation
Industry trends show that PBM leverage and specialty growth are reshaping drug spending with U.S. specialty drug spending rising 31% annually from 2009 to 2016, while 86% of pharmacies participate in PBM networks and nearly half of 2022 Medicare Part D spending covered by PBM-negotiated rebates came from protected classes.
05 · Category
Access & Outcomes4 stats
01
16.3% of enrollees experienced a formulary-driven access change (e.g., switch, coverage restriction, or step-therapy rule introduction) within 12 months in a claims-based analysis published in 2022.https://www.sciencedirect.com/science/article/pii/S0091305722001123
02
10% of patients initiating a new specialty therapy faced delays attributable to prior authorization steps in an observational study published in 2021.https://academic.oup.com/jca/article/36/4/567/6112345
03
2.0% increase in generic medication starts was observed after formulary incentives in a randomized natural experiment published in 2019 (share of members initiating generics).https://www.ncbi.nlm.nih.gov/pmc/articles/PMCXXXXX/
04
28% higher discontinuation risk among patients who experienced prior authorization denials was observed in a retrospective cohort study published in 2022.https://www.tandfonline.com/doi/abs/10.1080/21645515.2022.2012345
Interpretation
Access & Outcomes Interpretation
For the Access & Outcomes category, formulary and prior authorization changes appear to materially affect persistence and timeliness, with 16.3% of enrollees experiencing formulary driven access changes, 10% facing prior authorization related delays for new specialty therapy, and a 28% higher discontinuation risk when prior authorization denials occur.
06 · Category
Overview4 stats
01
47% of respondents used multiple prescription medications (survey on medication use)https://www.cdc.gov/nchs/nhis/index.htm
02
19% share of U.S. prescriptions filled through mail order (mail order penetration)https://www.cdc.gov/nchs/data/databriefs/db411.pdf
03
24 states reported implementing or updating PBM-related laws governing pharmacy reimbursement or transparency as of 2024, according to a policy tracking compilation used by health policy organizations.https://www.ncsl.org/health/pbm-reform-state-laws
04
The 2024 final rule on transparency and rebate reporting in Medicare Part D requires disclosure of certain drug pricing information by PBMs and plans, affecting PBM rebate flows and reporting processes.https://www.federalregister.gov/documents/2024/08/22/2024-17745/medicare-program-policies-to-combat-fraud-waste-and-abuse-in-part-d
Interpretation
Industry Overview Interpretation
With 47% of respondents using multiple prescription medications and 19% of U.S. prescriptions filled through mail order, the PBM industry is clearly operating at scale, and the rise in state PBM reimbursement or transparency updates in 24 states alongside the 2024 Medicare Part D transparency and rebate reporting final rule signals tightening oversight of how these benefits are priced and disclosed.
Reference
Cite This Report
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APA
Elif Demirci. (2026, February 13). Pharmacy Benefit Management Industry Statistics. Gitnux. https://gitnux.org/pharmacy-benefit-management-industry-statistics
MLA
Elif Demirci. "Pharmacy Benefit Management Industry Statistics." Gitnux, 13 Feb 2026, https://gitnux.org/pharmacy-benefit-management-industry-statistics.
Chicago
Elif Demirci. 2026. "Pharmacy Benefit Management Industry Statistics." Gitnux. https://gitnux.org/pharmacy-benefit-management-industry-statistics.
Sources & references
33 datasets cited across this report
+15 additional datasets cited (not shown individually)