Q&A: Transparent, Pass-Through PBMs Gaining Traction Over Big 3

In a recent report from the National Alliance of Healthcare Purchaser Coalitions, employers’ use of transparent, pass-through pharmacy benefit managers (PBMs) is growing rapidly compared with the Big 3—CVS Caremark, Optum Rx, and Express Scripts. With transparency living at the heart of new-wave PBMs gaining traction, experts believe that the way pharmacy benefits are distributed in the US could look significantly different in the near future.

“It's refreshing to see the traction. I don't expect the Big 3 to go away,” Bill Wolfe, COO at WriteWise and former President of Aetna’s Pharmacy Management team, told Drug Topics. “Their integrated offerings do have some value, but I think that having some transparency and really focusing on patient engagement, as well as focusing on the outcome and on managing costs at the same time that you're managing quality, is gaining traction.”

Through his work with WriteWise, like many of the rising PBMs in the marketplace, Wolfe and his team are attempting to revolutionize the way pharmacy and insurance benefits are managed in the future. In part 2 of our interview with him, Wolfe provided further insight into the changing PBM landscape. He discussed how transparency and patient engagement are taking center stage for beneficiaries across the country.

Get expert insights from a pharmacy industry expert with years of experience in the pharmacy benefit space. | image credit: Worawut / stock.adobe.com

Get expert insights from a pharmacy industry expert with years of experience in this space and understand how PBM control has led to new life in the marketplace, detailing what potentially could be in store for patients, pharmacists, employers, and more in the future.

READ MORE: How Pharmacy is at the Forefront of an Evolving Prescription Benefits Landscape

Drug Topics: Can you start by discussing the current state of pharmacy benefit managers in the US and how they’ve risen to the notoriety that so often surrounds them today?

Bill Wolfe: There are really 2 factors that have driven what is essentially a triopoly, although there's some promising news coming out in that regard. But what we refer to as the Big 3—so basically, CVS Caremark; Optum, United Healthcare; and Express Scripts and Cigna. These 3 PBMs, up until very recently, have been in excess of 70% for the entire marketplace. The 2 factors that got us to this point are really, they did aggressive acquisition strategies, kind of roll-ups to grow. While doing that, they created scale, which became too important, relative to how pharmacy benefits are primarily sourced today, which is via spreadsheet looks of last year's claims recast against new rebates and discounts and guarantees at the rebate and discount level.

[It appears] to show what you would have saved last year, but don't tell you what you're going to spend next year. Oftentimes, and it's thematically an issue and why the PBMs have come under such scrutiny, folks go through this exercise every year or every few years, think, ‘Okay, I got a new deal. I'm going to save money,’ and then they don't. Even though the PBMs hit their guarantees at the discount and rebate levels, the client still spends. The trends can be single digits, double digits. The costs just keep going up, while the consumer also continues to pay more out of pocket.

We're really at a crossroads in the industry in terms of there being heavy focus now on why is that the case. There hasn't been a lot of transparency. It's a very opaque and complicated industry to understand. In all candor, the large PBMs haven't done enough or a lot—starting to do some things—to solve that issue, or to better explain exactly what it is they do and why they're bringing value.

Drug Topics: A new report shows alternative, transparent PBMs are rising as the Big 3 have declined. Do you believe we are at a turning point in regard to prescription drug benefit distribution in the US?

Bill Wolfe: [It’s] absolutely at a crossroads. I think, as you referenced, it appears that the pass-through, what I would call start-up or challenger PBMs, have started to gain some access. They have created processes that take the pharmacy benefit to a place where it's more high-touch and engagement with the member, better understanding around alternate ways to source medications, as well as really taking member interaction to a higher level. Prior authorization kind of gets a bad name in the health care space, when the fact of the matter is, every health plan that I've worked with, the prior authorization process has been as much about getting the right medication to the right person at the right time and creating an outcome and making sure they don't take something that might be detrimental to their health, as much as it's been about cost—certainly, you can't deny that cost plays in there as well.

What these PBMs are doing that is gaining them traction is, first of all, they are actually demonstrating savings. They're demonstrating savings, even though they're not winning that spreadsheet battle because they do not have the scale of the Big 3. It really proves the point that, as a PBM, if you focus on the member, focus on managing the benefit, and if you are aligned with the client because of the fact that you only make admin fees, or you only get paid additionally when there are savings, versus the disjointed and misalignment of the larger PBMs, who have always made money when the client spends more money.

At some level, there's the conflict of interest of them operating the fulfillment centers and being the provider of the product they're supposed to be managing, as well as just the dynamic of how their economics have evolved over time, where they had certain profit buckets, whether it was spread on retail or admin fees on rebates. Then, purportedly, we're giving the pharmacy benefit administration away for free. Well, as we know, nothing is free.

It's refreshing to see the traction. Obviously, competition is good. I don't expect the Big 3 to go away. Obviously, they have the infrastructure and the wherewithal and the balance sheets to continue to play a role in the space. Their integrated offerings do have some value, but I think that having some transparency and really focusing on patient engagement, as well as focusing on the outcome and on managing costs at the same time that you're managing quality, is gaining traction.

READ MORE: Q&A: How GLP-1 Complexities Highlight Challenges in Pharmacy Benefits

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REFERENCE

Lutton L. Big three PBM use falls, transparent PBM use more than doubles, annual survey shows. Managed Healthcare Executive. September 9, 2025. Accessed September 29, 2025. https://www.managedhealthcareexecutive.com/view/big-three-pbm-use-falls-transparent-pbm-use-more-than-doubles-annual-survey-shows