Plan sponsors are more willing to shop for a new pharmacy benefit manager (PBM) than at any point in the past decade. A new industry survey shows most still don't know what their current contract actually allows them to do about it.
Those are two of the sharper findings from the 2026 Pharmacy Benefit Manager Customer Satisfaction Report, published by Pharmaceutical Strategies Group (PSG), a pharmacy benefits consultancy and EPIC company. PSG surveyed 250 benefits leaders representing employers, health plans, and health systems in May and June. Overall PBM satisfaction stabilized at 7.2 on a 10-point scale, nearly unchanged from 2025 but down from a high of 8.2 in 2021, according to the report. PSG received no financial support for the survey and states it is solely responsible for the findings.
The stabilization masks a more telling signal on renewal intent. Plan sponsors' likelihood of renewing their PBM contract without issuing a competitive RFP fell to 6.4 in 2026, the lowest point in the survey's 10-year history. That figure held above 8.0 every year from 2017 through 2020. The gap between how satisfied plan sponsors say they are and how likely they are to simply renew has widened considerably.
Employers rated their PBMs higher than health plans did across most functions. Customers of smaller, non-Big 3 PBMs continued to report greater overall satisfaction than Big 3 customers, though that advantage narrowed in 2026. The Big 3 refers to CVS Health, Express Scripts, and OptumRx. Non-Big 3 customer satisfaction dropped from 7.9 in 2025 to 7.3, while Big 3 customer satisfaction edged up slightly.
The survey points to revenue transparency as the area where trust is most clearly fraying. Sources of revenue ranked last across six transparency dimensions measured, with a mean score of 2.7 on a five-point scale. One in five respondents said their PBM was not at all transparent about how it makes money, a figure unchanged from 2025.
Non-Big 3 customers scored their PBMs substantially higher across all six transparency measures, including data access, formulary strategies, utilization management, audit rights, and rebate disclosures. That pattern connects to a broader shift in the PBM market: smaller employers have been leaving the Big 3 over contract transparency gaps and fiduciary concerns, a trend documented in separate PSG research on the employer PBM market published earlier in this year.
The Consolidated Appropriations Act of 2026 (CAA 2026), signed on February 3, will require PBMs to pass through 100 percent of rebates to qualifying self-funded ERISA plans and eliminate spread pricing. It also mandates detailed semiannual disclosures to plan sponsors, with most provisions taking effect on January 1, 2029.
Advisers working with clients on three-year PBM contracts today are in a position to negotiate disclosure and pass-through language ahead of those requirements. PBM contracts negotiated or renewed now may well govern the relationship when the law comes into force.
Specialty drug management has been a persistent source of dissatisfaction in PSG's research. Just 55 percent of respondents were satisfied with their PBM's competitive net pricing for specialty medications, according to the survey. Only 37 percent were satisfied with site-of-care and provider reimbursement strategies for specialty drugs in the medical benefit, the lowest-rated item in the specialty section.
Interest in carving out specialty pharmacy from the primary PBM contract has grown in response, with more than half of respondents indicating at least moderate interest in that strategy. The practical obstacle is contract clarity. Among all respondents, 41 percent said they were unsure whether their agreement permits the use of carve-out vendors, and only 15 percent could do so without restrictions or penalties. Advisers who have reviewed those terms in a client's contract have a concrete advantage as plan sponsors begin treating specialty pharmacy as a separable line item rather than a bundled service.
The demand for change is broad and consistent across plan sponsor types. Nearly two-thirds of respondents rated their desire for change in the pharmacy benefit management industry at 7 or above on a 10-point scale. Most expected recent regulatory and enforcement developments to produce only minor to moderate improvements in transparency. The FTC's settlement with Express Scripts in 2026 and growing scrutiny of rebate group purchasing organizations (GPOs) were recognized as occurring, but respondents were skeptical about their depth of impact.
What the survey captures, across satisfaction, transparency, and carve-out interest, is a client base that has outpaced its own contracts. The appetite for different arrangements is there; the contractual knowledge to act on it often isn't.
