Pharmacy Benefit Managers (PBMs)
CCPA believes insurance industry middlemen, known as Pharmacy Benefit Managers (PBMs), institute harmful policies and practices that exacerbate patient access challenges for the sake of greater profits. Policymakers should address how PBM practices impact access, affordability, and outcomes for patients.
While PBMs were initially tasked with processing pharmacy claims, their role and influence within the health care system and prescription drug supply chain has evolved and expanded over time so that they now control, costs, formularies, doctors’ ability to prescribe medication, and pharmacies’ ability to provide medications to their patients. PBMs lack oversight and regulation.
- Policies are shifting a greater cost burden onto patients. Over the last five years, the average premium for family coverage has increased by 24%, compared to a 28% increase in workers’ wages and inflation of 23% (KFF).
- Patients abandon their medications when costs go up. When out-of-pocket treatment costs reach or exceed $250, 70% of patients abandon their prescriptions at the pharmacy counter. In 2020 alone, patients starting a new therapy abandoned 55 million prescriptions at pharmacies.
- “US health plans are adopting benefit designs that shift greater financial burden to patients through higher deductibles, additional copay tiers, and coinsurance. Prior systematic reviews found that higher cost was associated with reductions in both appropriate and inappropriate medications” (NIH).
Key Resources
PBM oversight and transparency are critical to ensure unfair, discriminatory practices stop and greater affordability and access for patients.
Read the CCPA Founder & Director, Liz Helms’ letter to the editor in Read Clear Health HERE.
You can read CCPA’s policy on PBMs HERE: 2025 PBM Issue Overview.
Research
- FTC Releases Second Interim Staff Report on Prescription Drug Middlemen Report finds PBMs charge significant markups for cancer, HIV, and other critical specialty generic drugs (FTC, January 2005).
- The middlemen — The Opaque Industry Secretly Inflating Prices (New York Times).
- Federal Trade Commission, FTC Releases Interim Staff Report on Prescription Drug Middlemen (FTC, July 9, 2024).
- House Committee on Oversight and Accountability Chairman James Comer (R-Ky.) issued a report that said in part: The three largest PBMs have used their position … to enact anticompetitive policies and protect their bottom line (House Oversight Committee).
- 75% of all equivalent prescription claims were processed by three companies: CVS Health(including Caremark and Aetna), Express Scripts, and the OptumRx business of UnitedHealth (DrugChannels).
- Auditor’s Report: Pharmacy Benefit Managers Take Fees of 31% on Generic Drugs Worth $208M in One-Year Period (Ohio Auditor of State).
- Three PBMS cover 180 million lives in the United States, or roughly 78% of Americans whose pharmacy benefits are managed by a PBM (Applied Policy Issues Brief).
- CVS Health, Express Scripts, and the OptumRx are among the top 25 companies in the U.S. (Patients Not PBMs/Forbes Top 25 list).
- Washington State Pharmacy Association, New Study Reveals Discrepancies in Drug Pricing by Pharmacy Benefit Managers, Costing Employers and Hurting Pharmacies in Washington State, June 25, 2024.
- The ERISA Industry Committee, PBM Group Letter to Congress, February 3, 2025.
- TransparencyRx, a coalition of industry experts and stakeholders, led by licensed transparency PBMs.