FTC says prescription middlemen are squeezing Main Street pharmacies

Prescription drug middlemen — also known as pharmacy benefit managers — are lining their pockets by inflating drug prices, including overcharging cancer patients, the Federal Trade Commission said Tuesday.  

"The FTC's interim report lays out how dominant pharmacy benefit managers can hike the cost of drugs — including overcharging patients for cancer drugs," FTC Chair Lina M. Khan said in a news release. "The report also details how PBMs can squeeze independent pharmacies that many Americans — especially those in rural communities — depend on for essential care."

Pharmacy Benefit Managers began, decades ago, as administrators, validating and processing pharmacy benefits provided by separate insurance plans. After years of acquisitions, that's no longer the case, as the FTC lays out in its report.

PBMs now serve as vertically integrated health plans and pharmacists, wielding enormous control over the availability and cost of drugs by negotiating the terms and conditions for access to prescription medications for hundreds of million of Americans.

The three largest PBMs — CVS Caremark, Express Scripts and OptumRX — now manage almost 80% of all prescriptions filled in this country, the FTC noted. If the next three largest — Humana Pharmacy Solutions, MedImpact and Prime — are included, the six will oversee 94% of prescription drug claims in the U.S. 

All of the six largest PBMs run mail order and specialty pharmacies and one — CVS Caremark — operates the country's biggest retail pharmacy chain. Five of those six are now part of corporate health care conglomerates, including three of the five biggest health insurers in the country. 

Bad deal for patients

The setup is a dire one for many Americans, with roughly three in 10 adults surveyed by KFF (formerly known as the Kaiser Family Foundation) reporting rationing or skipping doses of prescription medications because of the cost.

The scenario is also fostering pharmacy deserts, especially in rural parts of the country, which saw 20% of independent retail pharmacies close from 2013 to 2022. "Certain PBMs may be steering patients to their affiliated pharmacies and away from unaffiliated pharmacies," the FTC stated. 

Affiliated pharmacies received significantly higher reimbursement rates than those paid to unaffiliated pharmacies for two case study drugs, according to the regulator's findings. "These practices have allowed pharmacies affiliated with the three largest PBMs to retain levels of dispensing revenue well above estimated drug acquisition costs, resulting in nearly $1.6 billion of additional revenue on just two cancer drugs in under three years," the report states. 

PBMs and brand drugmakers at times negotiate rebates that are conditioned on limiting access to potentially lower cost generic alternatives, potentially cutting off patient access to lower-cost medicines, the FTC said. 

The interim staff report is part of an ongoing probe launched in 2022 by the FTC, and serves as a possible sounding board for action as U.S. lawmakers look for culprits behind the high cost of prescription drugs.  

Georgia Rep. Buddy Carter, a pharmacist and Republican, called on the FTC to finish its probe and start enforcement actions if and when it finds "illegal and anti-competitive" practices.  

"I'm proud that the FTC launched a bipartisan investigation into these shadowy middlemen, and its preliminary findings prove yet again that it's time to bust up the PBM monopoly," Carter said Tuesday in a statement.

The Pharmaceutical Care Management Association bashed what the PBM trade group called a biased report "based on anecdotes and comments from anonymous sources and self-interested parties" along with two "cherry-picked case studies."