The Federal Trade Commission (FTC) has unveiled damning evidence of systematic price inflation by the nation's three largest pharmacy benefit managers (PBMs), documenting $7.3 billion in revenue generated through markup practices on specialty generic drugs between 2017 and 2022.
The comprehensive investigation, detailed in the FTC's second interim report, examined 51 specialty generic drugs dispensed through commercial health plans and Medicare Part D prescription drug plans. The analysis revealed that Caremark Rx, Express Scripts, and OptumRx significantly marked up costs for life-saving medications, including treatments for heart disease, cancer, and HIV.
Markup Practices and Revenue Generation
The investigation uncovered a complex web of pricing practices that substantially increased drug costs. The three PBMs' affiliated pharmacies experienced a remarkable 42% compound annual growth rate in dispensing revenues above the National Average Drug Acquisition Cost from 2017 to 2021. Notably, the top 10 specialty generic drugs generated $6.2 billion in dispensing revenue, representing 85% of total revenue.
An additional $1.4 billion was accumulated through spread pricing - the practice of charging health plans more than what pharmacies receive for dispensing medications. These specialty drug operations proved highly lucrative, accounting for approximately 12% of operating income for the PBMs' parent healthcare conglomerates in 2021.
Impact on Healthcare Costs and Access
The financial burden of these practices fell heavily on both healthcare plans and patients. By 2021, plan sponsors paid $4.8 billion for specialty generic drugs, while patient cost-sharing reached $297 million. The growth rate of these expenses was particularly concerning, with commercial claims increasing at a 21% compound annual rate and Medicare Part D claims at 14-15% from 2017 to 2021.
Discriminatory Practices Against Independent Pharmacies
The FTC's report highlighted significant disparities in reimbursement rates between PBM-affiliated and independent pharmacies. Independent pharmacies consistently received lower reimbursements for virtually all analyzed generic drugs, creating an uneven playing field in the pharmaceutical marketplace.
B. Douglas Hoey, RPh, MBA, CEO of the National Community Pharmacists Association, criticized these practices as "wild profiteering and self-dealing," noting that PBM-affiliated pharmacies received up to 100% higher reimbursement rates than independent pharmacies for identical medications.
Regulatory Response and Industry Defense
FTC Chair Lina Khan emphasized the need for continued investigation and swift action against potentially illegal conduct. The commission voted unanimously to release the report, demonstrating strong regulatory concern about these practices.
The Pharmaceutical Care Management Association (PCMA), representing PBM interests, defended specialty pharmacies, claiming they offer cost savings and equivalent or superior service levels. They projected potential savings of $250 billion over the next decade through their practices.
Market Impact and Future Implications
The findings raise significant concerns about market competition and healthcare accessibility. The practice of steering patients to PBM-affiliated pharmacies, particularly evident in high-profit prescriptions marked up by more than $1,000, suggests potential anti-competitive behavior that may require regulatory intervention.
The investigation continues to examine these practices, with stakeholders calling for increased transparency and fairness in pharmaceutical pricing and distribution systems. The findings may lead to significant regulatory changes in how PBMs operate and influence drug pricing in the United States.
