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]
As of 2016, PBMs managed pharmacy benefits for 266 million Americans. In 2017, the largest PBMs had higher revenue than the largest pharmaceutical manufacturers, indicating their increasingly large role in healthcare in the United States.[3] However, in 2016 there were fewer than 30 major PBM companies in this category in the US,[1] and three major PBMs (Express Scripts, CVS Caremark, and OptumRx of UnitedHealth Group) comprise 78% of the market and cover 180 million enrollees.[1][needs update]
This consolidation and concentration has led to lawsuits and bipartisan criticism for unfair business practices.[4][5] By 2024, The New York Times,[6] Federal Trade Commission,[7][8] and many states Attorneys General[9][10] have accused pharmacy benefit managers of unfairly raising prices on drugs.
- ^ a b c d 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.
- ^ Schulman, Kevin A.; Richman, Barak D. (2018). "The Evolving Pharmaceutical Benefits Market". JAMA. 319 (22): 2269–2270. doi:10.1001/jama.2018.4269. ISSN 0098-7484. PMID 29625496. S2CID 4655676.
- ^ 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". NYTimes.
- ^ 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
:6was invoked but never defined (see the help page).