Frequently Asked Questions
How do Pharmacy Benefit Managers (PBMs) influence the cost of prescription drugs?
Pharmacy Benefit Managers (PBMs) play a significant role in determining the cost of prescription drugs by negotiating prices with drug manufacturers, managing drug formularies, and setting reimbursement rates for pharmacies. The recent FTC report highlights that the top PBMs often engage in practices that can increase drug prices, such as excluding lower-cost competitor drugs from their formularies in exchange for higher rebates from manufacturers. This lack of transparency and accountability can lead to higher costs for patients.
What impact do PBMs have on independent pharmacies?
PBMs often steer patients towards their own affiliated pharmacies, disadvantaging independent pharmacies. According to the FTC's interim report, this practice, known as self-preferencing, can significantly harm smaller, unaffiliated pharmacies by reducing their customer base and revenue. Additionally, PBMs' leverage in contractual negotiations can result in unfavorable terms for independent pharmacies, making it difficult for them to compete and provide essential services, especially in rural areas.
What steps is the FTC taking to address PBM practices?
The FTC is actively scrutinizing the practices of dominant PBMs to ensure they do not unfairly increase drug prices or limit access to affordable healthcare. The FTC's interim report condemns these practices and signals the agency's commitment to using all available tools and authorities to promote transparency, accountability, and fair competition in the healthcare market. This includes investigating and potentially taking action against PBMs that engage in anti-competitive practices or unfairly disadvantage independent pharmacies.
WASHINGTON D.C., July 9, 2024: The Federal Trade Commission (FTC) has issued an interim report condemning the top Pharmacy Benefit Managers (PBMs) for unfairly rigging the healthcare system to reap huge profits.
FTC Chair Lina M. Khan, “The FTC’s interim report lays out how dominant pharmacy benefit managers can hike the cost of drugs—including overcharging patients for cancer drugs.”
“The report also details how PBMs can squeeze independent pharmacies that many Americans—especially those in rural communities—depend on for essential care. The FTC will continue to use all our tools and authorities to scrutinize dominant players across healthcare markets and ensure that Americans can access affordable healthcare.”
Key insights in the report include:
- Concentration and vertical integration - the top 6 PBMs dispensed over 90% of prescriptions in the US in 2023
- Significant power and influence - the top PBMs control accessibility and pricing, yet provide no accountability or transparency
- Self-Preferencing - the top PBMs steer customers away from independently owned pharmacies towards their own affiliated businesses
- Unfair Contract Terms - "Evidence suggests that increased concentration gives the leading PBMs leverage to enter contractual relationships that disadvantage smaller, unaffiliated pharmacies."
- Efforts to limit access to low-cost competitors - "Evidence suggests that PBMs and brand pharmaceutical manufacturers sometimes enter agreements to exclude lower-cost competitor drugs from the PBM’s formulary in exchange for increased rebates from manufacturers."
Stay tuned to Heath Law Alliance as we follow this and other important healthcare issues.
You may view our PBM Resource Page, sign up for our free PBM Audit Guide, and please contact us if you have any questions regarding PBMs or PBM Audits.
MORE ARTICLES BY CATEGORY
Guidance for New Entrants on Navigating PBM Audit Complexities
New pharmacy owners face complex PBM audit requirements that demand strict documentation, accurate claims, and ongoing compliance. Establishing strong recordkeeping systems and proactive audit readiness can help prevent costly recoupments and protect long-term network participation.
Read More >>How Pharmacies Can Challenge Unfair PBM Audit Findings
PBM audits can leave pharmacies facing exaggerated findings, steep recoupments, and even network termination. With the right strategies and legal support, pharmacies can successfully challenge unfair results and protect their business.
Read More >>Top Red Flags That May Trigger a PBM Audit
PBM audits can be disruptive, costly, and often triggered by high prescription volumes, dispensing irregularities, or claim activity. Pharmacies can reduce risks through strong documentation, compliance, and legal support to challenge unfair findings and protect network status.
Read More >>Approaching the Telehealth Policy Cliff: Medicare Telehealth Flexibilities to Expire Next Week
Without further congressional action, COVID-19 era telehealth flexibilities are set to expire on September 30, 2025. Read more to learn about what’s set to change and key guidance for telehealth providers to prepare to adapt to pre-pandemic coverage rules.
Read More >>
