What happened
Drug Channels, citing Pharmaceutical Strategies Group’s 2026 Pharmacy Benefit Manager Customer Satisfaction Report, said satisfaction with alternative PBMs declined in 2026, narrowing their advantage over CVS Caremark, Express Scripts, and Optum Rx. PSG surveyed 250 benefits leaders across employers, health plans, health systems, and unions or Taft-Hartley plans. Together, they represented about 144 million covered lives, with nearly two-thirds of plans using the Big Three. Overall PBM satisfaction rose slightly, to 7.2 from 7.1 on a 10-point scale. The split, however, moved in opposite directions: Big Three customer satisfaction increased to 7.1 from 6.8, while non-Big Three customer satisfaction fell to 7.3 from 7.9. Drug Channels also highlighted weaker sentiment measures for non-Big Three PBMs. Net Promoter Score fell to +4 from +16, services relative to expectations dropped to 6.5 from 7.1, and three-year likelihood of renewing without a competitive RFP declined to 6.8 from 7.3. By comparison, Big Three customers’ expectations and renewal ratings held at 6.2, and their NPS remained negative at -22.
Why it matters
The immediate read is that alternative PBMs still hold a relative perception advantage. The harder part now, the source argues, is retention, not just winning RFP invitations. Drug Channels said non-Big Three PBMs scored higher on perceived transparency across all six areas PSG measured, with the largest gap in sources of revenue. Yet revenue transparency remained the lowest-rated category across all PBMs and was unchanged from 2025. Retention, not just RFP access. That matters because a softer renewal score and lower NPS suggest some clients may be finding that post-sale performance is less differentiated than the pitch.
For the market, this points to a more demanding 2027 selling season. Drug Channels said plan sponsors are inviting alternatives into RFPs and that some are changing vendors. It also cautioned that many new vendors subcontract services from major PBMs, meaning a contract switch may not remove every economic connection to a Big Three PBM. The likely implication is more scrutiny on affiliated pharmacies, rebate GPOs, and subcontracted services, especially where transparency is central to the sales story.
For employer-side PBM benchmarking, see RxPBM.ai. For broader drug channel developments, see RxNews.ai.
