The Federal Trade Commission (FTC) has announced an investigation into the nation’s six largest pharmacy benefit managers (PBMs). The targeted PBMs include CVS Caremark, Express Scripts, OptumRx, Humana, Prime Therapeutics, and MedImpact Healthcare Systems. PBMs are associated with the largest health insurance companies and mail-order and specialty pharmacies. These highly influential entities in the U.S. prescription drug system negotiate rebates and fees with drug manufacturers; they also write drug formularies and applicable policies and reimburse pharmacies for prescriptions.
The FTC’s inquiry is designed to bring transparency to PBMs and how they impact pharmacies, insurance companies, medical providers, and patients. More specifically, the FTC wants to know how PBMs affect the accessibility and affordability of prescription drugs. In particular, the FTC wants to explore the several allegedly common practices of PBMs, including:
- Charging unaffiliated pharmacies fees and clawbacks;
- Steering patients toward PBM-owned pharmacies;
- Conducting potentially unfair audits of independent pharmacies;
- Using complex and unclear methods to determine pharmacy reimbursement;
- Broadly mandating prior authorizations and other administrative restrictions;
- Using specialty drug lists and accompanying policies; and
- Utilizing rebates and fees from drug manufacturers to impact formulary design and the costs of prescription drugs to payers and patients.
