Satisfaction with pharmacy benefit managers has stabilized in 2026, though the likelihood of contract renewal without a competitive request for proposal declined, a new report from Pharmaceutical Strategies Group (PSG) found.
The report drew insights from 250 benefits leaders representing employers, health plans, healthcare organizations and union plans. Respondents were asked to rate satisfaction with PBMs on a 10-point scale, with overall satisfaction receiving a 7.2 score, up from 7.1 in 2025.
On a similar scale, likelihood to renew contracts without issuing competitive RFP fell to 6.4—which analysts note is the “lowest point in recent history.”
Moreover, a net promoter score (NPS) established for likelihood to recommend their PBM to a colleague was at -13, on a -100 to 100-point scale. Analysts note NPS for PBMs has “declined substantially” in the last five years.
“Customers are demanding more from their PBMs, especially when it comes to managing costs and providing greater visibility,” said Mike Medel, PSG senior vice president and practice lead of plan sponsors, in a statement. ”We’re also starting to see satisfaction decline among non-big three PBMs, which drives home that these challenges aren’t exclusive to the biggest players in pharmacy benefit management.”
Satisfaction among sponsors using the big three PBMs (CVS Caremark, Express Scripts and Optum Rx) increased to 7.1, up from 6.8 in 2025, while the score for those using non-big three PBMs fell from 7.9 to 7.3 between 2025 and 2026.
Sixty-nine percent of respondents report including at least one non-Big 3 PBM in their last RFP while 82% report they would be at least moderately interested in including non-big three PBMs if they ran procurements today.
Revenue sources for PBMs remains a transparency gap for respondents, as 20% rating their PBM as not as all transparent about revenue source.
The report notes, however, transparency did improve in regard to access to data, formulary strategies, utilization management strategies, audit rights and both paid and excluded rebates.
“We’re continuing to see that customers lack full visibility into how their PBM makes money and whether its revenue sources are creating conflicts of interest,” said Morgan Lee, Vice PSG president of research and marketing, in a statement. “There’s an opportunity for more transparency in this area, which would empower customers to make more informed decisions on strategies they may want to pursue to ensure their pharmacy benefit is managed in accordance with their priorities.”