A
new
analysis
from
the
American
Medical
Association
(AMA)
adds
to
the
growing
evidence
detailing
the
lack
of
competition
and
high
vertical
integration
in
the
pharmacy
benefit
manager
market.
The
paper
is
based
on
2022
and
2023
data
on
prescription
drug
plan
enrollees
and
comes
shortly
after
the
Federal
Trade
Commission
and
the
U.S.
House
Committee
on
Oversight
and
Accountability
released
similar
reports
on
PBMs.
The
AMA
found
that
OptumRx
was
the
largest
PBM
in
the
U.S.
in
2023
with
a
22.2%
share
in
the
rebate
negotiation
market,
followed
by
CVS
Caremark
with
an
18.9%
market
share,
Express
Scripts
with
a
15.5%
market
share
and
Prime
Therapeutics
with
a
10.6%
market
share.
Together,
these
four
PBMs
had
a
67%
share
of
the
national
PBM
market
in
2023.
There
was
also
serious
vertical
integration
of
insurers
with
PBMs
in
2023,
with
77%
of
commercial
and
Part
D
enrollees
in
a
prescription
drug
plan
where
the
insurer
and
PBM
were
vertically
integrated,
according
to
the
AMA.
When
looking
at
just
Part
D
prescription
drug
plan
lives,
88%
were
in
a
plan
where
there
was
vertical
integration,
compared
to
71%
in
commercial.
In
addition,
nine
of
the
10
largest
PBMs
share
ownership
with
health
insurers.
This
includes
OptumRx
(owned
by
UnitedHealth
Group),
CVS
Caremark
(owned
by
CVS
Health)
and
Express
Scripts
(owned
by
Cigna).
UnitedHealth
Group
was
the
largest
prescription
drug
plan
insurer
in
the
commercial
market
and
the
Medicare
Advantage
market,
with
a
13.2%
share
and
29.4%
share,
respectively.
CVS
Health,
meanwhile,
was
the
largest
prescription
drug
plan
insurer
in
the
standalone
market
with
a
27.2%
share,
according
to
the
AMA.
“As
PBMs
increasingly
act
in
their
own
self-interest
without
transparency
or
accountability,
drug
prices
rise
and
patients
face
health
risks
from
cost
prohibitive
drug
treatments,”
said
AMA
President
Bobby
Mukkamala,
M.D.,
in
a
statement.
“The
AMA’s
analysis
is
intended
to
provide
insight
to
help
policymakers
understand
the
anticompetitive
conditions
in
the
PBM
market
that
can
result
in
harm
to
patients.”
Mukkamala
added
that
the
AMA
supports
initiatives
aimed
at
increasing
transparency
and
holding
pharmacy
benefit
managers
accountable.
At
the
federal
level,
several
bipartisan
bills
have
been
introduced
targeting
PBMs.
This
includes
the
PBM
Reform
Act
introduced
by
Rep.
Earl
L.
“Buddy”
Carter
(R-Georgia)
in
July,
which
seeks
to
ban
spread
pricing
in
Medicaid.
There
is
also
the
Patients
Before
Monopolies
Act,
introduced
in
December
by
Senators
Elizabeth
Warren
(D-Massachusetts)
and
Josh
Hawley
(R-Missouri),
which
would
ban
PBMs
from
owning
pharmacies.
Photo:
z_wei,
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