Pharmacy Benefit Managers (PBMs) play a crucial role in controlling drug coverage and pricing for insurers, having emerged in the late 1960s. In 2023, major PBMs such as OptumRx, Express Scripts, and CVS Caremark managed approximately 79% of U.S. prescription claims. These entities negotiate drug prices and design formularies, which directly affect patient out-of-pocket costs. However, the tier placement of drugs within these formularies can complicate cost transparency, as the discounts PBMs negotiate are often kept secret [19a1b665].
The recent scrutiny of PBMs has intensified, particularly following a 2024 Federal Trade Commission (FTC) report that highlighted anticompetitive practices in insulin pricing. The report raised concerns about how PBMs' mergers with health insurers limit competition and how they may steer specialty prescriptions to affiliated pharmacies, further complicating the drug pricing landscape [19a1b665].
U.S. Senator Bernie Sanders has described the high costs of drugs as a moral issue, emphasizing the need for reform in the healthcare system. For instance, the list price for the weight-loss drug Wegovy is $1,349 per month in the U.S., compared to just $265 in Canada, illustrating the stark differences in drug pricing that many Americans face [19a1b665].
As the Justice Department and FTC continue their investigations into the practices of PBMs, experts are advocating for increased competition and regulation to improve drug pricing and accessibility for consumers. The ongoing investigations aim to address the rising costs of medications, which have led to significant rationing among patients [384084ee][dfce12cb].