The small-town drugstore closed for the last time on a clear and chilly afternoon in February. Jon Jacobs, who owned Yough Valley Pharmacy, hugged his employees goodbye. He cleared the shelves and packed pill bottles into plastic bins.Mr. Jacobs, a 70-year-old pharmacist, had spent more than half his life building his drugstore into a bedrock of Confluence, Pa., a rural community of roughly 1,000 people. Now the town was losing its only health care provider.Obscure but powerful health care middlemen — companies known as pharmacy benefit managers, or P.B.M.s — had destroyed his business.This has been happening all over the country, a New York Times investigation found. P.B.M.s, which employers and government programs hire to oversee prescription drug benefits, have been systematically underpaying small pharmacies, helping to drive hundreds out of business.The pattern is benefiting the largest P.B.M.s, whose parent companies run their own competing pharmacies. When local drugstores fold, the benefit managers often scoop up their customers, according to dozens of patients and pharmacists.Jon Jacobs packed up medicine on the day he closed his pharmacy in February.Jeff Swensen for The New York TimesMr. Jacobs hugged an employee.Jeff Swensen for The New York TimesNewly Created DesertsNearly 800 ZIP codes that had at least one pharmacy in 2015 now have none.

Both have campaigned for lower prescription costs. Kamala Harris has promised to expand President Biden’s policies. Donald Trump is a wild card.Insulin for $35 a month. A limit of $2,000 a year in out-of-pocket drug costs for older Americans. Billions of dollars in savings for Medicare resulting from drug negotiations.Whether these policies expand or, in the case of the negotiations, survive at all may be determined by the election in November.Vice President Kamala Harris, the Democratic nominee, has vowed to extend President Biden’s policies to more drugs and more Americans. She plans to use savings from expanding negotiations to help pay for a sweeping new proposal that would cover long-term care at home for people on Medicare.Former President Donald J. Trump, the Republican nominee, is a wild card. He has offered few specifics about what he would do on drug pricing.Last week, he reversed his position on a policy he had proposed in his first term that rattled pharmaceutical companies: tying drug prices to what other wealthy countries pay. In a second term, he would face pressure from some Republicans to undo Mr. Biden’s Medicare negotiation program — although he once promoted the same thing.Drug pricing has not featured prominently in a presidential campaign that has been dominated by immigration, abortion and the economy. Mr. Trump, in particular, rarely talks about the issue. Nor is it top of mind for many voters.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

The case takes aim at the major pharmacy benefit managers, agency officials said, claiming that they favored more expensive insulin products and forced patients to pay more.The Federal Trade Commission said on Friday that it had taken legal action against the three largest pharmacy benefit managers, accusing the drug middlemen of inflating insulin prices and steering patients toward higher-cost insulin products to increase their profits.The legal action targets CVS Health’s Caremark, Cigna’s Express Scripts and UnitedHealth’s Optum Rx and subsidiaries they’ve created to handle drug negotiations, agency officials said. The three collectively control 80 percent of prescriptions in the United States. Hired by employers and government health insurance programs like Medicare, pharmacy benefit managers, or P.B.M.s, are responsible for negotiating prices with drug makers, paying pharmacies and helping decide which drugs are available and at what cost to patients.Agency officials said they had filed an administrative complaint, which is not yet public, that accuses the P.B.M.s of distorting competition and harming consumers. The agency is seeking to prohibit the benefit managers from favoring medicines because those drugs make them more money.The agency’s five commissioners voted on the action, with the three Democratic appointees favoring it and the two Republicans recusing themselves.Rahul Rao, an F.T.C. official, said in a news release on Friday that the largest P.B.M.s “have extracted millions of dollars off the backs of patients who need lifesaving medications.”He said the agency’s legal action “seeks to put an end to the big three P.B.M.s’ exploitative conduct and marks an important step in fixing a broken system — a fix that could ripple beyond the insulin market and restore healthy competition to drive down drug prices for consumers.”We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

In a report, the regulator sharply criticized pharmacy benefit managers, a reversal from its longstanding hands-off approach to policing the companies.The Federal Trade Commission on Tuesday sharply criticized pharmacy benefit managers, saying in a scathing 71-page report that “these powerful middlemen may be profiting by inflating drug costs and squeezing Main Street pharmacies.”The regulator’s study signals a significant ramping up of its scrutiny of benefit managers under the agency’s chair, Lina Khan. It represents a remarkable turnabout for an agency that has long taken a hands-off approach to policing these companies.The F.T.C. has so far stopped short of bringing a lawsuit or other enforcement action against a benefit manager. But the industry fears that the report could lead to a formal investigation into its practices or to a lawsuit accusing benefit managers of anticompetitive conduct. The agency’s findings could also fuel legislative efforts in Congress and in the states to impose limits on the industry.The three largest benefit managers — CVS Health’s Caremark, Cigna’s Express Scripts and UnitedHealth Group’s Optum Rx — collectively process roughly 80 percent of prescriptions in the United States. Hired by employers and government health insurance programs like Medicare, benefit managers are responsible for negotiating prices with drug makers, paying pharmacies and helping decide which drugs are available and at what cost to patients.Benefit managers are supposed to save everyone money. But in recent years, the industry has grown more consolidated and has taken more control over how patients get their medicines, in a shift that critics say contributes to driving up drug costs.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

Here’s what to know about your pharmacy benefit manager and how to find out if you are being overcharged for medications.If you’ve ever had trouble getting a prescription drug, chances are you’ve run into a pharmacy benefit manager.These companies, known as P.B.M.s, play a crucial but often hidden role in deciding which drugs you can get and how much you will personally have to pay. They are middlemen in the maddeningly complex American health care system, working on behalf of your employer or government insurance programs like Medicare, which cover most of the costs of prescription drugs.The job of the P.B.M. is to save money on your medications. But The New York Times found that the three biggest P.B.M.s are often making you pay more than you should.Here’s what to know about your P.B.M. and how to find out if you are being overcharged.How do I know which P.B.M. I have?Most Americans rely on one of the big three P.B.M.s: CVS Caremark, Express Scripts or Optum Rx. Even if you have a smaller P.B.M. like Prime Therapeutics, you may be affected by the business practices of the three giants. (That’s because many smaller P.B.M.s delegate some of their dealings with drug companies and pharmacies to their larger competitors.)This is different from the health insurance that covers your doctors’ visits or a hospital stay. While you can typically pick your health plan during your employer’s open enrollment period every year, your P.B.M. is picked for you.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

An array of obstacles make it difficult for patients to obtain Wegovy or Zepbound. Finding Wegovy is “like winning the lottery,” one nurse practitioner said.Talk to people who have tried to get one of the wildly popular weight-loss drugs, like Wegovy, and they’ll probably have a story about the hoops they had to jump through to get their medication — if they could get it at all.Emily Weaver, a nurse practitioner in Cary, N.C., said she told her patients that finding Wegovy was “like winning the lottery.”Here are six reasons why.1. Demand is very high.Fueled in part by TikTok videos and celebrity testimonials, people are increasingly seeking prescriptions for appetite-suppressing medications. The drugs in this class have long been used to treat diabetes but more recently have been recognized for their extraordinary ability to help patients lose weight. The medications are injected weekly and have sticker prices as high as $16,000 a year.About 3.8 million people in the United States — four times the number two years ago — are now taking the most popular weight-loss drugs, according to the IQVIA Institute for Human Data Science, an industry data provider. Some of these prescriptions are for diabetes. The medicines are Novo Nordisk’s Ozempic and Wegovy (the same drug sold under different brand names), and Eli Lilly’s Mounjaro and Zepbound (also the same drug).We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.