Prime has largest share of ACA market

Thanks to Blue Plans’ commitment to the Health Insurance Marketplace, Prime serves 1 in 4 enrollees in the ACA market.

March 16, 2022

Once again Prime Therapeutics (Prime) is the pharmacy benefit manager (PBM) with the largest share of the health insurance markets created by the Affordable Care Act (ACA). February enrollment numbers show Prime serving 3.4 million members through the individual market and 2.3 million members through the small group business market. That’s nearly 25% of the roughly 24 million people covered through those marketplaces, according to Steven Heavrin, senior director, government segment programs.

“Blue Plans have been strong players since these markets opened in 2014,” Heavrin says. “As a result, Prime has been the largest PBM in this space since the very beginning.”

Maturing market brings opportunities

Initially, serving the ACA markets was a bumpy ride. With no historical data, risk management, high member utilization and pricing were challenges. Few plans entered the market in 2014. Many of them left in 2015 and 2016. “Blue Plans felt it was part of their mission to serve the individuals and small businesses in their communities,” Heavrin says. “Together, we learned a lot in those early years.”

As the market matures, pricing adjustments have settled down. That stability enables Heavrin to work closely with health plans to develop benefit design options that address the needs of their specific markets. “We’re studying designs that have worked in some areas, identifying best practices and bringing them to all our clients,” Heavrin says. “That’s contributing to steady growth for Prime and our clients.”

Now, more health plans are entering to compete with the Blues. But Heavrin says Blue Plans maintain a strong position. He points to one plan that had no competition and 100% of the HIM enrollment in its market in 2016. Five years later, there are 10 health plans competing in that marketplace — and the Blue still has 85% market share. “Their commitment to serving people in those early years is paying off,” Heavrin says. “People are sticking with the plans that have been there for them.”

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