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
Health Law Alliance Secures Major Victory as Federal Court Dismisses Lawsuit Against Independent Pharmacies
Health Law Alliance secured a major win for independent pharmacies with the dismissal of Cardinal Health’s lawsuit, exposing it as a baseless attempt to intimidate smaller providers. This outcome reinforces the firm’s commitment to protecting healthcare businesses from corporate overreach.
Read More >>DOJ’s 2025 National Health Care Fraud Takedown: What it Means for Telehealth Providers
The DOJ’s 2025 National Health Care Fraud Takedown charged 324 people in schemes totaling $14 billion in intended losses, including $1.17 billion tied to telemedicine and genetic‑testing fraud that implicated 49 defendants - signaling the government’s continued crack‑down on virtual‑care abuses. The surge in criminal and civil actions, coupled with CMS suspensions and the new DOJ‑HHS False Claims Act Working Group, warns telehealth providers to rigorously audit their compliance practices or risk severe penalties and exclusion from federal programs.
Read More >>Telehealth Audit Season: OIG Found 7 Percent Error Rate in Pandemic-Era E/M Billing
A 2024 OIG study found that 7% of E/M services billed during the pandemic were noncompliant with Medicare billing requirements. We break down OIG’s findings and explain what they mean in an era where RPM audits are on the rise.
Read More >>Health Law Alliance Earns Reinstatement for DME Supplier Whose Medicare Billing Privileges Were Unjustly Revoked
Due to Health Law Alliance’s advocacy, a prominent DME vendor in Texas had their billing privileges reinstated this week, without having to jump through the arduous, costly hoops of a fair hearing in front of an Administrative Law Judge or a Departmental Appeals Board review.
Read More >>
