AI Is Coming for Pharmacy Benefit Managers: Potential Winners and Losers

Pharmacy benefit managers control U.S. drug distribution by negotiating rebates, designing formularies, adjudicating claims, and influencing adherence. Modern AI can automate and optimize these high-volume, rules-driven processes through autonomous prior authorization, real-time formulary optimization, and rebate analytics. This creates structural pressure on the margin pools that have historically supported large PBMs. As AI-native vendors and adjacent platforms scale these capabilities, traditional PBM economics face disruption. The ranking identifies Cigna as most exposed due to its reliance on Express Scripts and Evernorth pharmacy benefit services, while Waystar is positioned as a clear beneficiary of payment-workflow automation. The remaining stocks are evaluated by how leveraged they are to these shifts in healthcare payment operations.

"Pharmacy benefit managers (PBMs) sit at the chokepoint of U.S. drug distribution. They negotiate rebates, design formularies, adjudicate claims, and steer patient adherence. Modern artificial intelligence (AI) is designed to compress each of these high-volume, rules-driven processes. As autonomous prior authorization, real-time formulary optimization, and AI-driven rebate analytics scale, the Big Three PBMs face a structural threat to their legacy margin pools, while AI-native vendors and adjacent platforms stand to benefit."

"Cigna Group ( NYSE: CI | CI Price Prediction) owns Express Scripts in its Evernorth unit, now its dominant earnings engine. Evernorth generated $58.44 billion in Q1 2026 revenue, with Pharmacy Benefit Services alone at $33.00 billion (+11% YoY). Cigna Healthcare shrank 21% after the HCSC Medicare divestiture. Adjusted EPS of $7.79 beat estimates for the fourth consecutive quarter, and management raised FY26 adjusted EPS guidance to at least $30.35."

"Here's the risk: Cigna flagged "expected lower contributions from large Pharmacy Benefit Services client relationships," pharmacy customer attrition, and "drug pricing changes or industry pricing benchmark shifts." AI-driven transparency tools and the company's rebate-free pharmacy benefit model are reshaping the rebate economics that historically powered Express Scripts. Shares are up just 4.2% year to date at $286.69, trading at a forward price-to-earnings (P/E) near 9, reflecting investor caution despite operational beats."

"Waystar ( NASDAQ: WAY) is the clearest beneficiary of healthcare's payment-workflow automation. Q1 2026 revenue rose 22.4% year over year to $313.87 million, with subscription revenue up 38% and adjusted EBITDA margin expanding to 43.1%. Net revenue retention"

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