Prime again dominates the ACA market

Once again, Prime Therapeutics (Prime) is the largest pharmacy benefit manager (PBM) serving the health insurance marketplace (HIM). According to the U.S. Department of Health and Human Services, more than 16.3 million people have enrolled for individual coverage under the Affordable Care Act (ACA). With 3.66 million HIM members, Prime serves 22% of the individual market.

In addition, Prime has 2.34 million HIM members in the small group marketplace. While total small group enrollment figures aren’t yet available, Prime estimates enrollment will again be around 9.4 million.

“Our Blue Plan owner-clients believe that serving the individual and small group market is part of their mission,” Steven Heavrin, senior director, HIM programs at Prime said. “As a result, Prime traditionally serves between 20% and 25% of the market.”

Prime’s 6 million HIM members in January 2023 is up from Prime’s 5.5 members in January 2022. Steven attributes the growth to several factors:

Prime’s recently announced acquisition of Magellan Rx Management (Magellan Rx) expands the HIM footprint even more. Prime added 40,000 additional members through Magellan Rx. Magellan Rx serves one health plan with a presence in the HIM market.

Blue commitment pays off

With no historical data, risk management and pricing were challenges when HIM was launched. Few plans entered the market in 2014. Many of them left in 2015 and 2016. Blue Plans stayed in. As the market matured, pricing adjustments settled down. Enrollees themselves aren’t jumping every year to the lowest premium option.

“That stability allows us to work closely with health plans to develop benefit design options that address the needs of their specific markets,” Heavrin said. “We’re studying designs that have worked in some markets, identifying best practices and bringing them to all our health plan clients. That’s contributing to our steady growth in the market.”