In the United States, a pharmacy benefit manager (PBM) is a third-party administrator of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program, and state government employee plans.[1][2] PBMs operate inside of integrated healthcare systems (e.g., Kaiser Permanente or Veterans Health Administration), as part of retail pharmacies (e.g., CVS Pharmacy), and as part of insurance companies (e.g., UnitedHealth Group).[1]
The role of pharmacy benefit managers includes managing formularies, maintaining a pharmacy network, setting up rebate payments to pharmacies, processing prescription drug claims, providing mail order services, and managing drug use. PBMs play a role as the middlemen between pharmacies, drug manufacturers, wholesalers, and health insurance plan companies.[3]
As of 2023, PBMs managed pharmacy benefits for 275 million Americans and the three largest PBMs in the US, CVS Caremark, Cigna Express Scripts, and UnitedHealth Group’s Optum Rx, make up about 80% of the market share covering about 270 million people[4][5] with a market of almost $600 billion in 2024.[6]
This consolidation and concentration has led to lawsuits and bipartisan criticism for unfair business practices.[7][8] In 2024, The New York Times,[9] Federal Trade Commission,[10][11] and many states Attorneys General[12][13] accused pharmacy benefit managers of unfairly raising prices on drugs.
Additionally, several states have created regulations and policies concerning PBM business practices.[14]
- ^ a b Feldman, Brian S. (March 17, 2016). "Big pharmacies are dismantling the industry that keeps US drug costs even sort-of under control". Quartz. Retrieved March 29, 2016.
- ^ Gryta, Thomas. "What is a 'Pharmacy Benefit Manager?'". Wall Street Journal. ISSN 0099-9660. Retrieved March 29, 2016.
- ^ Mattingly, T. Joseph, II; Hyman, David A.; Bai, Ge (November 3, 2023). "Pharmacy Benefit Managers: History, Business Practices, Economics, and Policy". JAMA Health Forum. 4 (11): e233804. doi:10.1001/jamahealthforum.2023.3804. ISSN 2689-0186. PMID 37921745.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ "Pharmacy Benefit Managers: The Powerful Middlemen Inflating Drug Costs and Squeezing Main Street Pharmacies". Federal Trade Commission. July 9, 2024. Retrieved November 18, 2024.
- ^ "5 Things to Know About PBMs' Influence on Drug Costs and Access". AJMC. August 2, 2024. Retrieved November 18, 2024.
- ^ https://www.statista.com/topics/11037/pharmacy-benefit-managers/?utm_source=substack&utm_medium=email#topicOverview; Text, Statistics Can Display More up-to-Date Data Than Referenced in the (February 2024). "Pharmacy benefit managers". Statista. Retrieved December 22, 2024.
{{cite web}}:|last1=has generic name (help); External link in|last1= - ^ Cite error: The named reference
:7was invoked but never defined (see the help page). - ^ Gibson, Kate (July 9, 2024). Lee, Anne Marie (ed.). "FTC says prescription middlemen are squeezing Main Street pharmacies". CBS News. Retrieved August 14, 2024.
- ^ Cite error: The named reference
:1was invoked but never defined (see the help page). - ^ Weixel, Nathaniel (July 9, 2024). "FTC report slams pharmacy 'middlemen' for seemingly driving up prices, limiting access". The Hill.
- ^ Abelson, Reed; Robbins, Rebecca (July 8, 2024). "F.T.C. Slams Middlemen for High Drug Prices, Reversing Hands-off Approach". The New York Times.
- ^ Chatlani, Shalina (August 15, 2024). "To lower prescription drug costs, states head to the courthouse". Stateline (news). Retrieved August 18, 2024.
- ^ Cite error: The named reference
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