What the FTC's study of pharmacy benefit managers found

On June 7, 2022, the five members of the Federal Trade Commission voted unanimously to send compulsory orders to the six largest pharmacy benefit managers in the country, seeking information on how they run prescription drug benefits for health plans and employers. The orders were issued under Section 6(b) of the FTC Act¹, which the agency describes as authority "to conduct studies without a specific law enforcement purpose." In 2023 the FTC added orders to three rebate aggregators, also called group purchasing organizations, bringing the study to nine companies, the FTC said in its July 2024 announcement².

So far the study has produced two interim staff reports, issued in July 2024 and January 2025. A separate administrative lawsuit over insulin rebates followed, and two of the three PBM groups named in it have settled.

For generic drug users, the study matters more than its insulin headlines suggest. The second interim report dealt entirely with generic drugs, and both reports measured PBM pricing against NADAC, the federal survey of what pharmacies pay for drugs. This piece covers what the FTC asked for, what its staff found, and where the related case stands.

What the FTC asked the PBMs to produce

A 6(b) study is a fact-finding exercise. The orders are mandatory, but the resulting reports carry no penalties on their own. According to the FTC's June 2022 announcement¹, the orders covered seven areas:

• fees and clawbacks charged to unaffiliated pharmacies
• methods of steering patients toward PBM-owned pharmacies
• audits of independent pharmacies
• the formulas used to set pharmacy reimbursement
• prior authorization and other administrative restrictions
• specialty drug lists and related policies
• how manufacturer rebates and fees shape formularies and costs for payers and patients

Most of those topics touch generics directly, since pharmacy reimbursement for generics is set by PBM pricing lists rather than by a published list price. Our explainer on how pharmacies get paid walks through the mechanics.

The first interim report, July 2024

On July 9, 2024, the commission voted 4 to 1² to release the first interim staff report³. The top three PBMs processed nearly 80 percent of the roughly 6.6 billion prescriptions dispensed in the US in 2023, and the six largest handled more than 90 percent. Pharmacies affiliated with the top three accounted for nearly 70 percent of specialty drug revenue, the FTC said.

Its case study involved two generic cancer drugs. Staff found that PBM-affiliated pharmacies were often paid 20 to 40 times NADAC for them, and that those pharmacies kept nearly $1.6 billion in dispensing revenue above NADAC from 2020 into 2022. It also said independent retail pharmacies in rural America declined by about 10 percent between 2013 and 2022 (see our piece on independent and chain pharmacies), and that some rebate contracts between PBMs and manufacturers excluded generics and biosimilars in ways that "may cut off patient access to lower-cost medicines."

The second interim report and specialty generics

On Jan. 14, 2025, the commission voted 5 to 0⁴ to release a second report, titled Specialty Generic Drugs: A Growing Profit Center for Vertically Integrated Pharmacy Benefit Managers⁵. It examined 51 specialty generic drugs, covering 882 national drug codes, dispensed from 2017 through 2022. The core finding was that pharmacies affiliated with the three largest PBMs took in $7.3 billion in dispensing revenue above NADAC on those drugs. Staff got there by subtracting $2.7 billion in estimated acquisition cost from $10.0 billion in revenue, and called the result likely an underestimate.

Drugs named in the report's heat map include generic versions of cancer treatments such as abiraterone, imatinib and capecitabine, a long list of HIV drugs, multiple sclerosis drugs including dalfampridine and dimethyl fumarate, and the pulmonary hypertension drugs sildenafil and tadalafil. From 2017 to 2021, what plan sponsors and patients paid for these drugs grew at a compound annual rate of 21 percent on commercial claims and 14 to 15 percent in Part D, according to the FTC.

Part D looked different. Affiliated pharmacies filled fewer of these prescriptions than unaffiliated ones, which the report said "may suggest that PBMs have less ability to influence patient pharmacy choices in Part D," partly because of Medicare's any willing pharmacy rules. It added that "our analysis still finds very significant markups of drugs in Part D." Of the $1.4 billion in estimated spread income, about 90 percent came from claims at unaffiliated pharmacies and 97 percent from commercial plans.

GxRadar's own data show how far acquisition costs for one of those drugs have fallen. In our analysis of CMS NADAC files⁸, sildenafil 20 mg tablets cost pharmacies an average of $0.683 each in January 2014 and $0.052 in October 2026, which puts 90 tablets at about $4.65. The NADAC history for tadalafil on our site covers the 5 mg strength, which is not the strength used for pulmonary hypertension. Neither figure says anything about what a given plan pays, which is the gap the FTC was measuring. Our guide to what NADAC measures explains the benchmark's limits.

A dispute inside the commission

Commissioners did not all agree on how the work was handled. The second report came with a concurring statement⁶ from Commissioner Andrew Ferguson, joined by Commissioner Melissa Holyoak. They voted to release it but wrote that they would have preferred to wait and issue only a final report. The statement called the second report a marked improvement over the first because it relied mainly on data from the 6(b) orders, and disputed the claim that PBM noncompliance was the main cause of delay, blaming the chair's "resource-allocation decisions" instead. Ferguson wrote that he was committed to concluding the study with a final report, which would require staff to work with the order recipients to understand the context of the data they produced.

The insulin rebate case

The study also had an enforcement offshoot. In September 2024 the FTC filed an administrative complaint over insulin rebates against the three largest PBMs and their affiliated rebate groups. By mid-2026 two of the three respondent groups had reached settlements and the third had been withdrawn from adjudication to consider a proposed consent agreement, according to the FTC's case page for Docket No. 9437⁷, which still listed the matter as pending at its last update on July 14, 2026.

What has happened since the reports

Congress acted before the FTC finished. The Consolidated Appropriations Act, 2026, signed Feb. 3, 2026, includes PBM provisions⁹ that require detailed drug-level reporting to Medicare plan sponsors, with each drug's average NADAC listed alongside what the plan paid pharmacies, and that require PBMs serving employer plans to pass through all rebates. Most of those rules start in 2028, as our explainer on the 2026 federal PBM law describes. For background on how rebates shape coverage, see tiered formularies explained, and for related coverage, our law and policy desk.

Two items remain open. One is the final 6(b) report Ferguson committed to in January 2025, which GxRadar could not find published as of early November 2026. The other is the consent agreement with the third PBM group in the insulin case.