Top three insurers reaped $7.3 billion through their drug middlemen’s markups, FTC says

The three largest drug middlemen inflated the costs of numerous life-saving medications by billions of dollars over the past few years, the Federal Trade Commission said in a report released Tuesday.

The top pharmacy benefit managers (PBMs) — CVS Health’s Caremark Rx, Cigna’s Express Scripts and UnitedHealth Group’s OptumRx — generated roughly $7.3 billion through price hikes over about five years starting in 2017, the FTC said.

The “excess” price hikes affected generic drugs used to treat heart disease, HIV and cancer, among other conditions, with some increases more than 1,000% the national average costs of acquiring the medications, the commission said.

The FTC also said these so-called “Big Three” health care companies — which it estimates administer 80% of all prescriptions in the U.S. — are inflating drug prices “at an alarming rate, which means there is an urgent need for policymakers to address it.”

The commission has been raising antitrust concerns about these companies’ market dominance and pricing practices for years, particularly in light of major insurers’ ownership of large pharmacy middlemen.

Tuesday’s findings come on the heels of an earlier PBM report the FTC released last year, which slammed the Big Three and their next-biggest rivals as “enormous healthcare conglomerates that can exercise vast control over huge swaths of the healthcare sector.”

Some of the steepest drug markups were “hundreds and thousands of percent,” according to Tuesday’s report, which highlights just how profitable specialty drugs have become for the three leading PBMs. Cancer drugs alone made up nearly half of the $7.3 billion, the commission wrote, with multiple sclerosis medications accounting for another 25%.

Dispensing highly marked-up specialty drugs was a massive income stream for the companies in 2021, the FTC found. Out of tens of thousands of drugs dispensed, the top 10 specialty generics alone made up nearly 11% of the companies’ pharmacy-related operating income that year, the agency estimated. Across the 51 drugs the agency analyzed, the Big Three’s price-markup revenue surged from $522 million in 2017 to $2.1 billion in 2021, the report said.

CVS Health said in a statement that it “is inappropriate and misleading to draw broad conclusions from cherry-picked ‘specialty generic’ outliers” and that the company’s “top priority is to make health care more affordable.”

OptumRx said that it helped eligible patients save $1.3 billion last year and estimated that the median out-of-pocket payment for these patients was $5. Express Scripts said the FTC’s report contained “misleading conclusions.”

The report marks one of the commission’s final moves under the Biden administration. President-elect Donald Trump has tapped Andrew Ferguson, one of the agency’s current five commissioners, to succeed Chair Lina Khan, a move widely expected to bring far more pro-business policies. However, the first Trump administration did make several efforts to lower prescription drug costs.

Tuesday’s report, which contains the most detailed government findings to date on PBM drug markups, suggests that the large PBMs “may be steering these prescriptions to their own affiliated pharmacies.” Researchers and advocates have been publishing reports for years on specialty drug markups, arguing that drug middlemen are a key culprit in the steep prices Americans pay for medicines.

The commission’s first report in its investigation into PBMs, released in July, found that the largest of them “profit at the expense of patients by inflating drug costs and squeezing Main Street pharmacies.” That report flagged markups of two specialty cancer drugs exceeding 1,000%, moves that generated their affiliated pharmacies hundreds of millions of dollars.

Express Scripts sued the commission two months after the first report, arguing that regulators had made unsubstantiated, false and biased claims about the industry. Three days later, the FTC sued Express Scripts and the other two top PBMs, alleging anticompetitive practices that artificially inflated insulin prices. All three companies have disputed those accusations.

The FTC filed a motion to dismiss the Express Scripts case last month, though the judge has yet to rule on it. The agency’s own case against the PBMs is ongoing.