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1Scan for outdated or missing drivers - takes under a minute2Clear out junk files and repair common Windows errors3Fix the driver behind crashes, sound loss and screen glitchesA pharmacy benefit manager (PBM) is a company a health plan or plan sponsor hires to administer some or all of its prescription drug benefit. PBMs can process prescription claims, negotiate drug-price concessions, set up pharmacy networks, and administer coverage rules. Their choices can affect a plan’s spending, a pharmacy’s reimbursement, and what a patient pays—but those amounts are not the same, and PBM contracts vary.
What a PBM does
A PBM sits between a health plan and the pharmacies and manufacturers involved in providing prescription drugs. It is not itself the insurer, drug manufacturer, or dispensing pharmacy. Depending on its contract, a PBM may handle several parts of a plan’s prescription benefit:
- Claims processing: When a pharmacy submits a prescription claim, the PBM checks it against the plan’s coverage and payment rules.
- Formulary administration: A formulary is the plan’s list of covered medicines and related conditions. PBMs may help develop or administer it.
- Pharmacy networks: PBMs can contract with pharmacies and help determine which pharmacies are in a plan’s network.
- Price negotiations: PBMs may negotiate rebates and other concessions from drug manufacturers.
- Pharmacy payment arrangements: A PBM may contract with pharmacies and determine claim reimbursement under its agreement with the plan.
These responsibilities are not identical across PBMs or contracts. The Government Accountability Office (GAO) describes PBMs as providing services to health plans and plan sponsors, while the Centers for Medicare & Medicaid Services (CMS) identifies reporting categories that include rebates, pharmacy channels, generic dispensing, and spread pricing. GAO’s 2024 report, its 2019 report, and CMS’s drug-data guidance describe these roles and arrangements.
How a prescription benefit flows through a PBM
- A health plan or plan sponsor hires a PBM to manage specified parts of its prescription benefit.
- A patient presents a prescription at a pharmacy. The pharmacy submits a claim to the PBM.
- The PBM applies the plan’s coverage and network rules and returns the claim decision and payment information.
- The pharmacy dispenses the medicine and receives payment under its contract. The patient pays any applicable cost sharing at the point of sale.
- Manufacturer rebates or other concessions may be negotiated and reported later, changing the plan’s net cost after the prescription has been dispensed.
This is a simplified sequence, not a universal accounting flow. Contracts, payment timing, and the route by which money moves differ across plans and products.
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Why drug spending, pharmacy payment, and your cost can differ
Several figures are often described as “the price” of a prescription, but they measure different things. The amount charged or paid at the pharmacy counter is not necessarily the plan’s final net cost after later concessions. Pharmacy reimbursement is also a separate contract amount, and a patient’s cost sharing depends on the plan’s rules.
- Gross spending is measured before rebates and other price concessions are deducted.
- Net plan spending reflects the effect of applicable concessions, subject to how they are accounted for and passed through under the arrangement.
- Pharmacy reimbursement is what the pharmacy receives under its contract for a claim; it should not be confused with the manufacturer’s price or the patient’s payment.
- Patient out-of-pocket cost is the amount the patient owes under the plan at the point of sale. A later rebate does not automatically mean the patient paid less at the counter.
For historical context, GAO reported that rebates and other price concessions in Medicare Part D reached $29 billion in 2016—20% of gross expenditures that year. Gross Part D expenditures were $145.1 billion and net expenditures were $116.1 billion. These are GAO figures for Medicare Part D in 2016, not current estimates for all drugs or insurance markets. GAO’s analysis explains why gross and net spending should not be treated as interchangeable.
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How rebates and spread pricing work
Rebates and other concessions
A manufacturer may provide a rebate or another price concession after a drug is dispensed. The concession can lower a health plan’s net cost, but it does not, by itself, establish what the patient paid at the pharmacy or how much the dispensing pharmacy received. The effect on patients depends on the plan’s cost-sharing rules and the PBM’s contract with its client.
Spread pricing
CMS defines reported spread pricing as the aggregate difference between what a qualified health plan pays a PBM and what the PBM pays retail and mail-order pharmacies. This describes a possible payment arrangement; its inclusion in reporting rules does not mean every PBM contract uses spread pricing. CMS’s definition and reporting guidance concern qualified health plans and should not be generalized into a claim about every insurance arrangement.
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How formularies and pharmacy networks affect patients
A formulary can determine whether a medicine is covered, what coverage conditions apply, and what alternatives a plan recognizes. A network determines which pharmacies can fill prescriptions under the plan’s preferred terms. Together, these choices can influence a patient’s access to a medicine or pharmacy and the cost sharing that applies.
The Federal Trade Commission (FTC) said in its 2024 interim staff report that leading PBMs have significant influence over formulary and pharmacy-network decisions. That is the FTC’s assessment, not a claim that every PBM makes every coverage decision independently of its plan client. The FTC report release also found that nearly 80% of approximately 6.6 billion U.S. prescriptions in 2023 were processed by the three largest PBMs. The figure refers to U.S. prescription volume in 2023, not the share of all drug spending or all patients.
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What government reports say—and what the figures cover
Agency findings help describe PBM practices, but each figure has a defined scope. The FTC’s interim reports, in particular, analyze specified data and should not be read as a complete accounting of every PBM contract or the entire market.
- Specialty generic drugs: The FTC’s 2025 interim staff report estimated more than $7.3 billion in dispensing revenue above estimated acquisition costs at affiliated pharmacies during 2017–2022. The analysis covered 51 specialty generic drugs, or 882 National Drug Codes, for members of commercial and Medicare Part D plans managed by the three largest PBMs for which the FTC had relevant data. It used the National Average Drug Acquisition Cost (NADAC) as its acquisition-cost measure. This is not an estimate of all PBM revenue.
- Separate spread-pricing estimate: In that same defined specialty-generic analysis and period, the FTC estimated $1.4 billion in separate spread-pricing income. This is a distinct measure; it should not be added to the $7.3 billion as though both represented the same kind of markup.
- Patient cost concerns: The FTC’s 2024 release said nearly 30% of Americans surveyed reported rationing or skipping doses because of high medicine costs. The release does not provide enough survey-method detail to treat this as a current estimate for the U.S. population.
The FTC Chair characterized the 2025 staff report by saying that the three major PBMs “hiked costs for a wide range of lifesaving drugs, including medications to treat heart disease and cancer.” That is the Chair’s description of an interim staff report, not a court finding. The underlying FTC findings and their scope are set out in the FTC’s 2025 release.
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How PBMs are overseen
Federal reporting
Federal law requires PBMs and qualified health plan issuers to report specified prescription-benefit information to CMS. Categories include the shares of prescriptions filled through retail and mail-order channels, generic dispensing, rebates and other concessions, and spread pricing. CMS says it may share the collected information only with GAO, the Congressional Budget Office, and states for Exchange purposes, so it cannot make that collected data public. As a result, the public does not have a complete ledger of the reported qualified-health-plan PBM data. CMS explains the reporting and data-sharing limits.
State laws
States regulate PBM arrangements in different ways, including through licensing or registration, reporting, rules about rebates and spreads, pharmacy-network protections, and patient-access provisions. GAO’s 2024 review of five selected states—Arkansas, California, Louisiana, Maine, and New York—found that all five had enacted laws addressing drug pricing and pharmacy payments, while four had enacted a PBM duty-of-care or related requirement. Those results describe the five states GAO selected, not a complete count of state laws or a current legal guide for every state. GAO’s report details the selected-state review.
FTC matters
FTC enforcement developments can change. As of the FTC case page’s July 14, 2026 update, the agency reported a settlement agreement with Caremark and Zinc Health Services and an earlier February 2026 settlement with Express Scripts entities. The page described commitments involving transparency, patient out-of-pocket costs, and community pharmacies, while listing the administrative matter as pending. These are agency-reported settlement commitments, not a final resolution of every issue in the administrative proceeding. For the current status and terms, consult the FTC case page.
What to compare when choosing or reviewing a health plan
A plan’s PBM may be invisible to a member, but the plan’s benefit design and pharmacy arrangements are not. When comparing plans or asking an employer or insurer about its PBM arrangement, useful questions include:
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- What is the plan’s total net cost after rebates, fees, and other concessions, and how is that figure calculated?
- Do rebates affect a member’s point-of-sale cost, or are they accounted for only after the claim?
- How are pharmacy reimbursements determined, and does the contract include spread pricing?
- What drugs are on the formulary, what exceptions are available, and what covered alternatives exist?
- Which local, mail-order, or independent pharmacies are in the network, and what access limits apply?
- What reporting, audit rights, and safeguards address conflicts of interest?
These questions do not identify a universally best PBM model. A plan sponsor may value negotiated concessions that lower its net spending, while patients and pharmacies may focus on point-of-sale costs, access, and reimbursement. Those outcomes depend on the contract and plan design, so one measure alone cannot establish whether an arrangement benefits every party.
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