Industry news

By: Wendell Potter, As seen in HEALTH CARE un-covered

A number of states – including Texas – have considered or passed legislation to require insurers to meet network adequacy standards. Three years ago, Texas lawmakers passed a bill with unanimous support that gave the state’s department of insurance more authority to bring insurers into compliance.

The Texas Department of Insurance (TDI) testified in 2023, prior to the passage of the bill, that more than 90% of insurers’ health plan networks in the state did not meet the statutorily mandated network adequacy standards. You wouldn’t think those standards should have been so hard for a health plan to meet. Plans in Texas that serve urban areas couldn’t make patients travel more than 30 miles for primary or general hospital care or more than 75 miles to see a specialist or receive specialty hospital care. Rural patients had a 60-mile limit for primary and general hospital care.

By: Rebecca Pifer Parduhn, As seen in Healthcare Dive

 Average premiums for ACA plans increased 58% after more generous financial assistance expired, while enrollment in low-premium, high-deductible bronze plans jumped, according to new federal data. 

As seen in Drug Channels

 Three is still the magic number for pharmacy benefit managers (PBMs).

For 2025, 80% of all equivalent prescription claims were processed by three companies: the CVS Caremark business of CVS Health, the Express Scripts business of Cigna, and the Optum Rx business of UnitedHealth Group. Express Scripts continued to pull ahead of its peers, while CVS Caremark’s claim volume declined for the second year.

Independent PBMs continued to gain business from these larger PBMs, showing fragmentation at the margins. Many smaller PBMs still rely on their larger competitors for claims processing, network management, and rebate negotiation. So even if a plan sponsor chooses an alternative PBM, the Big Three can still win with behind-the scenes economics.

Below, we draw on DCI's new 2026 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers to break down the latest market share data for the largest companies.

The Big Three PBMs’ dominance persists, but they face growing regulatory and competitive constraints. The largest PBMs are restructuring their businesses in response to client demands, legislative changes, and legal pressures. The emerging Net Pricing Drug Channel will accelerate these shifts, forcing changes in how PBMs generate profits, structure contracts, and justify their role in the drug channel.