Medical disclaimer
This page is for informational purposes. Drug pricing, formulary, and interaction data reflects publicly disclosed information; individual experience varies by plan and effective date. Consult your pharmacist or physician for personalized guidance. Do not change or stop a prescribed medication based on this page.
PBM Market Concentration
s1 ~80% of U.S. prescription claims in 2023 were processed by the three largest PBMs: CVS Caremark, Express Scripts, and OptumRx, per the FTC.
s2 3 PBMs are now vertically integrated with the three largest U.S. health insurers (CVS Health/Aetna, Cigna/Express Scripts, UnitedHealth Group/Optum).
s3 66% of all retail prescription drug spending in the U.S. is administered by a PBM.
s4 $600B+ in annual U.S. prescription drug spending flows through PBM-administered claims processing.
s5 6 entities (the top 3 PBMs plus their integrated specialty pharmacies and GPOs) account for the dominant share of rebate negotiation, per the FTC.
s6 ~70% share of U.S. prescription claims processed by the top 3 PBMs in 2019, vs ~80% by 2023, indicating ongoing consolidation.
s7 $10.6B in combined PBM segment operating income reported by the three largest parent companies in 2023.
Source: 10-K filings (CVS Health, Cigna, UnitedHealth Group); summarized in Drug Channels Institute coverage
s8 2019 was the year of GAO's first dedicated PBM report (GAO-19-498), establishing the federal-investigative baseline for current FTC work.
s9 79% of total U.S. prescriptions adjudicated through the three largest PBMs by claim count, per FTC findings.
s10 2022: FTC launched 6(b) study into PBM business practices, the regulatory action whose interim findings now anchor the policy debate.
Spread Pricing
s11 100s-1000s% markups by the three largest PBMs on several specialty generic drugs, above their National Average Drug Acquisition Cost, per FTC findings.
s12 $1.4B+ in spread-pricing revenue generated by the three largest PBMs on a sample of specialty generic drugs over a multi-year window analyzed by the FTC.
s13 7,500%+ peak markup observed by the FTC on individual specialty generic drug claims in the analyzed sample.
s14 3 specialty drug categories (oncology, HIV, multiple sclerosis) where FTC documented the largest spread-pricing margins.
s15 21 states have enacted some form of PBM spread-pricing prohibition or transparency law as of 2025.
s16 2019: Ohio's Medicaid program publicly disclosed $244M in spread pricing extracted by PBMs over a single fiscal year, triggering nationwide policy attention.
s17 $3.43 average per-claim PBM gross profit margin on commercial brand-name drugs, per FTC analysis.
s18 ~50% of independent pharmacies report below-cost reimbursement on at least some PBM-adjudicated claims, per industry surveys cited in FTC analysis.
s19 ~10% of independent retail pharmacies have closed since 2010, with PBM reimbursement pressure cited as a contributing factor.
s20 100%+ markup on insulin glargine biosimilar observed in PBM spread-pricing analysis published by the FTC.
Formulary Tier Distribution
s21 3 different tier counts (4-, 5-, and 6-tier) in active use across the 15 major U.S. insurer formularies tracked by OmniRx, plus closed formularies for VA and TRICARE.
Source: OmniRx 2026 PBM Cross-Reference
s22 5-tier is the modal commercial formulary structure, used by Aetna, Cigna, Humana, most BCBS plans, and standard Medicare Part D.
Source: CMS Medicare Part D formulary files; OmniRx formulary database
s23 6-tier systems used by UnitedHealthcare and Anthem, splitting specialty into preferred and non-preferred sub-tiers.
Source: OmniRx UHC formulary record
s24 $0-$15 typical 30-day copay for Tier 1 preferred generics across major commercial plans.
Source: OmniRx insurer formulary database; KFF Employer Health Benefits Survey 2024, Section 9
s25 25-50% typical coinsurance for Tier 4 and Tier 5 specialty drugs on commercial plans.
s26 ~$100B+ in annual U.S. specialty drug spending now placed on Tier 4 or Tier 5 by major commercial PBMs.
Source: IQVIA Institute annual U.S. medicine use and spending reports
s27 15 major U.S. insurer formularies indexed in the OmniRx 2026 dataset, including UHC, BCBS, Aetna, Cigna, Humana, Kaiser, Anthem, Ambetter, Molina, Medicare Part D, TRICARE, Medicaid, VA, Marketplace, Medicare Advantage.
Source: OmniRx 2026 data.json
s28 25 drug-coverage explainers in OmniRx covering Ozempic, Wegovy, Humira, Eliquis, Jardiance, Mounjaro, Dupixent, Xarelto, Entresto, Keytruda, insulin, and 14 other high-cost or high-prevalence drugs.
Source: OmniRx formulary section
s29 Quarterly formulary update cadence used by most major commercial insurers, with mid-year changes possible for new FDA approvals and safety updates.
Source: CMS Medicare Part D rules; OmniRx insurer formulary records
s30 4-tier structure used by Kaiser Permanente, the simplest tier system among major commercial insurers tracked.
Source: OmniRx Kaiser formulary record
s31 Closed formulary structures used by VA and TRICARE, with non-formulary drugs requiring an exception or off-formulary process.
s32 ~3,500 drugs on a typical Medicare Part D plan formulary, per CMS.
s33 2 categories (antidepressants, antineoplastics) are CMS-protected classes that Medicare Part D plans must cover substantially all drugs within, limiting tier-placement variance.
s34 6 protected classes total under Medicare Part D: anticonvulsants, antidepressants, antineoplastics, antipsychotics, antiretrovirals, immunosuppressants.
s35 Up to 3x patient out-of-pocket variance documented in KFF and Commonwealth Fund analyses for the same drug across plans, driven by tier placement and coinsurance differences.
Prior Authorization
s36 ~30% of brand-name prescriptions require prior authorization on major commercial formularies, per AMA and KFF analyses.
s37 7.4M prior authorization determinations issued by Medicare Advantage plans in 2022, per KFF analysis of CMS data.
s38 ~7% of Medicare Advantage prior authorization requests fully or partially denied in 2022, per KFF.
s39 82% of Medicare Advantage prior authorization denials that were appealed were fully or partially overturned, per KFF.
s40 ~10% of Medicare Advantage denials are appealed, leaving the majority of denials unchallenged, per KFF.
s41 2026: CMS Interoperability and Prior Authorization rule begins phased implementation, requiring electronic prior authorization APIs by 2027.
s42 ~14 days typical median turnaround for non-urgent commercial prior authorization decisions, per AMA survey data.
s43 ~25% of physicians report a prior authorization-related serious adverse event for a patient in their care, per AMA surveys.
s44 Most GLP-1s (Ozempic, Wegovy, Mounjaro, Zepbound) require prior authorization on major commercial formularies for any indication.
s45 Step therapy required by most commercial insurers for branded statins, with patients required to fail atorvastatin or rosuvastatin generics first.
Step Therapy
s46 ~20% of commercial drug claims subject to step therapy or fail-first protocols, per IQVIA and KFF analyses.
Source: IQVIA Institute reports; KFF analysis
s47 29 states have enacted step therapy reform legislation establishing override or exception processes, as of 2025.
Source: NCSL step therapy policy tracker
s48 2019: CMS allowed Medicare Advantage plans to use step therapy for Part B drugs, expanding the protocol's reach.
s49 Common classes for step therapy: GLP-1s, biologics, branded statins, branded antidepressants, branded PPIs, branded migraine medications.
Source: OmniRx formulary database; AMA step therapy advocacy
s50 2-3 typical number of generics or preferred brands a patient must trial and fail before a non-preferred brand is approved.
Source: OmniRx insurer formulary records (UHC, Aetna, Cigna)
s51 Ozempic for weight loss generally not covered by commercial insurance; off-label step therapy not applicable because Wegovy is the FDA-approved semaglutide product for obesity.
Source: OmniRx Ozempic coverage record
s52 Humira biosimilars required by most commercial PBMs as first-line in 2024-2026, with patients required to switch from reference Humira when stable.
s53 Insulin step therapy: most commercial plans require trying preferred insulin glargine (Lantus or Basaglar or Semglee) before approving Tresiba or Toujeo.
Source: OmniRx insulin coverage record
s54 ~30 days minimum trial-and-fail period at each step before exception is generally considered, on most commercial plans.
Source: OmniRx formulary records (Aetna, Cigna, UHC plan documents)
s55 Override protocols available on most commercial plans when documented intolerance, contraindication, or prior failure exists; details vary by plan.
Source: OmniRx insurer formulary records
Patient Assistance Programs
s56 55 patient assistance programs cataloged in the OmniRx 2026 PAP database.
Source: OmniRx 2026 data.json
s57 65.5% of OmniRx-tracked PAPs are manufacturer-run (36 of 55).
Source: OmniRx 2026 PBM Cross-Reference
s58 23.6% of OmniRx-tracked PAPs are nonprofit (13 of 55), led by PAN Foundation, Partnership for Prescription Assistance, and HealthWell Foundation.
Source: OmniRx 2026 PAP database
s59 7.3% of OmniRx-tracked PAPs are federal programs (4 of 55): Medicare Extra Help / LIS, Medicaid, VA, IHS.
Source: OmniRx 2026 PAP database
s60 43.6% of OmniRx-tracked PAPs cap eligibility at 400% of the Federal Poverty Level (24 of 55), the modal income floor.
Source: OmniRx 2026 PBM Cross-Reference
s61 $60,240 approximate 2025 income at 400% FPL for an individual, the modal PAP eligibility ceiling.
s62 25.5% of OmniRx-tracked PAPs extend eligibility to 500% FPL (14 of 55).
Source: OmniRx 2026 PAP database
s63 7.3% of OmniRx-tracked PAPs have no income test (4 of 55), typically discount cards or copay programs for commercially insured patients.
Source: OmniRx 2026 PAP database
s64 215 distinct drug-coverage entries across the OmniRx PAP catalog (counting each drug-program pairing).
Source: OmniRx 2026 data.json
s65 4 PAPs each cover Eliquis and Jardiance, the highest overlap rate in the OmniRx catalog.
Source: OmniRx 2026 PAP database
s66 3 PAPs each cover Mounjaro, Trulicity, Humalog, Farxiga, Symbicort, Imbruvica, Xarelto, Ozempic, NovoLog, Tresiba, Humira, Rinvoq, Opdivo.
Source: OmniRx 2026 PAP database
s67 Up to 100% off covered Pfizer medications via the Pfizer RxPathways manufacturer PAP for eligible uninsured or underinsured patients.
Source: Pfizer RxPathways; OmniRx 2026 PAP database
s68 Lilly Cares: Eli Lilly's manufacturer PAP, covers insulin, Trulicity, Mounjaro, Verzenio, and other Lilly portfolio drugs for eligible patients.
Source: Lilly Cares Foundation
s69 PAN Foundation: largest U.S. nonprofit copay assistance program, with 70+ disease-fund cycles annually.
Source: PAN Foundation
s70 Co-pay accumulators and maximizers: PBM tools that prevent manufacturer copay assistance from counting toward the patient's deductible, used by most major commercial PBMs as of 2024-2026.
Drug Interactions
s71 53 drug-drug or drug-substance interactions in the OmniRx 2026 interaction database.
Source: OmniRx 2026 data.json
s73 79.2% of OmniRx interactions graded Severe or Moderate combined (42 of 53).
Source: OmniRx 2026 interaction database
s74 10 interactions in the catalog feature ibuprofen (18.9% of all records), the most-flagged drug.
Source: OmniRx 2026 interaction database
s75 8 interactions feature alcohol, the second-most-flagged substance.
Source: OmniRx 2026 interaction database
s76 5 each: lisinopril and warfarin appearance counts in the OmniRx interaction catalog.
Source: OmniRx 2026 interaction database
s77 ~24% of U.S. adults take 3+ chronic medications, increasing polypharmacy interaction risk, per CDC NCHS.
s78 2015: FDA strengthened its NSAID warning label to reflect cardiovascular risk and interaction concerns.
s79 FAERS: FDA Adverse Event Reporting System receives ~2M+ adverse event reports per year from clinicians, manufacturers, and consumers.
Source: FDA FAERS public dashboard
s80 12 drugs sit at the intersection of OmniRx's interaction catalog and drug-coverage formulary records: insulin, Ozempic, metformin, lisinopril, atorvastatin, levothyroxine, gabapentin, omeprazole, sertraline, Adderall, amoxicillin, birth control.
Source: OmniRx 2026 PBM Cross-Reference
Generic Substitution
s81 ~91% of U.S. retail prescriptions are filled with a generic, per FDA and IQVIA data.
Source: FDA generic drug facts; IQVIA Institute
s82 ~$408B in cumulative U.S. healthcare savings from generic drug use over the most recent decade analyzed.
s83 80-85% typical price decline from brand to first-generic launch within 12 months when 4+ generic manufacturers enter.
s84 Tier 1: typical placement for FDA-approved AB-rated generics on most commercial formularies.
Source: OmniRx insurer formulary records
s85 Levothyroxine: FDA cautions against switching between brand and generic without monitoring TSH due to narrow therapeutic index.
s86 ~$10/mo or less typical retail cash price for metformin, lisinopril, atorvastatin, sertraline, omeprazole generics on Cost Plus, GoodRx, or pharmacy discount programs.
Source: Mark Cuban Cost Plus Drugs; GoodRx
s87 Authorized generics: brand manufacturers' own generic versions, used strategically to compete with independent generic entry; accounted for ~5% of generic dispensing in recent FTC analysis.
Source: FTC Authorized Generics study
Specialty Drug Pricing
s88 ~50% of total U.S. prescription drug spending is now on specialty drugs, despite specialty drugs being ~2-3% of prescriptions by volume.
s89 $100K+ annual cost typical for specialty oncology, biologic, and rare disease therapies on commercial plans.
s90 25-50% coinsurance typical on Tier 4 or Tier 5 specialty drugs on commercial plans.
s91 $2,000 annual Medicare Part D out-of-pocket cap for 2025 under the Inflation Reduction Act, the most significant patient-cost cap change in Part D's history.
s92 10 drugs selected for the first round of Medicare Part D price negotiation under the IRA, with negotiated prices effective 2026.
s93 ~38%-79% negotiated price reductions across the 10 IRA-negotiated drugs vs prior list prices, per HHS announcement.
s94 Specialty pharmacy dispensing increasingly routed to PBM-owned specialty pharmacies; FTC documents this vertical integration as a competition concern.
Mark Cuban Cost Plus Drugs
s95 2022: Mark Cuban Cost Plus Drug Company launched as a transparent cost-plus-15%-plus-pharmacy-fee model.
Source: Cost Plus Drugs about page
s96 2,500+ medications now available through Cost Plus Drugs as of 2025-2026.
Source: costplusdrugs.com
s97 Cost + 15% + $5: the public Cost Plus pricing formula (manufacturer cost plus 15% margin plus $5 dispensing fee plus shipping).
Source: Cost Plus Drugs pricing model
s98 Imatinib (generic Gleevec): Cost Plus published price of $30-$40 for a 30-day supply, vs $9,000+ at typical retail with PBM intermediation, the headline example used in FTC and KFF Health News coverage.
s99 2024: Cost Plus expanded into Medicare Part D plan partnerships, the first major step toward integrating its model into mainstream insurance coverage.
s100 Cash-pay alternatives (Cost Plus, GoodRx, Amazon Pharmacy) frequently beat insurance-routed prices for generic maintenance medications, per OmniRx and KFF Health News analyses.