{
  "name": "OmniRx 2026 PBM Spread Pricing and Drug Coverage Cross-Reference",
  "version": "1.0.0",
  "datePublished": "2026-05-09",
  "dateModified": "2026-05-09",
  "license": "https://creativecommons.org/licenses/by/4.0/",
  "publisher": {
    "name": "OmniRx",
    "url": "https://omnirx.org"
  },
  "url": "https://omnirx.org/research/pbm-spread-pricing-2026/",
  "description": "Pre-computed aggregates merging three first-party OmniRx datasets: 53 drug interactions, 55 patient assistance programs, and 50 insurer formulary or drug coverage records. Editorial review pending for clinical accuracy.",
  "ymyl": true,
  "editorialReview": "pending",
  "primary_sources": [
    {
      "name": "FTC Interim Staff Report on PBMs (Jul 2024)",
      "url": "https://www.ftc.gov/reports/pharmacy-benefit-managers-report"
    },
    {
      "name": "FTC Second Interim Staff Report on PBMs (Jan 2025)",
      "url": "https://www.ftc.gov/news-events/news/press-releases/2025/01/ftc-releases-second-interim-staff-report-prescription-drug-middlemen"
    },
    {
      "name": "openFDA Drug API",
      "url": "https://open.fda.gov/apis/drug/"
    },
    {
      "name": "FDA Adverse Event Reporting System (FAERS)",
      "url": "https://www.fda.gov/drugs/questions-and-answers-fdas-adverse-event-reporting-system-faers/fda-adverse-event-reporting-system-faers-public-dashboard"
    },
    {
      "name": "CMS Medicare Part D Formulary Files",
      "url": "https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovgenin"
    },
    {
      "name": "GAO Report on PBMs (GAO-19-498)",
      "url": "https://www.gao.gov/products/gao-19-498"
    },
    {
      "name": "KFF Health Costs Tracker",
      "url": "https://www.healthsystemtracker.org/"
    },
    {
      "name": "Mark Cuban Cost Plus Drug Company",
      "url": "https://costplusdrugs.com"
    },
    {
      "name": "Drug Channels Institute (Adam Fein)",
      "url": "https://www.drugchannels.net/"
    }
  ],
  "dataset_counts": {
    "drug_interactions": 53,
    "patient_assistance_programs": 55,
    "formulary_records_total": 50,
    "formulary_records_insurer": 15,
    "formulary_records_drug_coverage": 25,
    "formulary_records_guide": 10
  },
  "interactions": {
    "n": 53,
    "severity_distribution": {
      "Severe": 26,
      "Moderate": 16,
      "Mild": 7,
      "None": 4
    },
    "severe_share_pct": 49.1,
    "top_drugs_by_interaction_count": [
      {
        "drug": "Ibuprofen",
        "count": 10
      },
      {
        "drug": "Alcohol",
        "count": 8
      },
      {
        "drug": "Lisinopril",
        "count": 5
      },
      {
        "drug": "Warfarin",
        "count": 5
      },
      {
        "drug": "Metformin",
        "count": 4
      },
      {
        "drug": "Aspirin",
        "count": 3
      },
      {
        "drug": "Potassium",
        "count": 3
      },
      {
        "drug": "Lexapro",
        "count": 3
      },
      {
        "drug": "Tramadol",
        "count": 3
      },
      {
        "drug": "Acetaminophen",
        "count": 2
      },
      {
        "drug": "Amoxicillin",
        "count": 2
      },
      {
        "drug": "Prednisone",
        "count": 2
      },
      {
        "drug": "Metoprolol",
        "count": 2
      },
      {
        "drug": "Melatonin",
        "count": 2
      },
      {
        "drug": "Clopidogrel",
        "count": 2
      }
    ]
  },
  "patient_assistance_programs": {
    "n": 55,
    "type_distribution": {
      "manufacturer": 36,
      "nonprofit": 13,
      "federal": 4,
      "discount": 2
    },
    "income_eligibility_distribution_pct_fpl": {
      "138%FPL_Medicaid_threshold": 1,
      "150%FPL": 1,
      "300%FPL": 3,
      "350%FPL": 1,
      "400%FPL": 24,
      "500%FPL": 14,
      "600%FPL": 5,
      "no_income_test": 4,
      "unspecified": 2
    },
    "modal_income_floor": "400% FPL (24 of 55 PAPs, 43.6%)",
    "total_distinct_drug_coverage_entries": 215,
    "top_drugs_by_pap_coverage_count": [
      {
        "drug": "Eliquis",
        "papCount": 4
      },
      {
        "drug": "Jardiance",
        "papCount": 4
      },
      {
        "drug": "Mounjaro",
        "papCount": 3
      },
      {
        "drug": "Trulicity",
        "papCount": 3
      },
      {
        "drug": "Humalog",
        "papCount": 3
      },
      {
        "drug": "Farxiga",
        "papCount": 3
      },
      {
        "drug": "Symbicort",
        "papCount": 3
      },
      {
        "drug": "Imbruvica",
        "papCount": 3
      },
      {
        "drug": "Xarelto",
        "papCount": 3
      },
      {
        "drug": "Ozempic",
        "papCount": 3
      },
      {
        "drug": "NovoLog",
        "papCount": 3
      },
      {
        "drug": "Tresiba",
        "papCount": 3
      },
      {
        "drug": "Humira",
        "papCount": 3
      },
      {
        "drug": "Rinvoq",
        "papCount": 3
      },
      {
        "drug": "Opdivo",
        "papCount": 3
      }
    ]
  },
  "formularies": {
    "n_total": 50,
    "insurer_records": 15,
    "drug_coverage_records": 25,
    "guide_records": 10,
    "insurer_slugs": [
      "unitedhealthcare-formulary-2026",
      "blue-cross-blue-shield-formulary-2026",
      "aetna-formulary-2026",
      "cigna-formulary-2026",
      "humana-formulary-2026",
      "kaiser-permanente-formulary-2026",
      "anthem-formulary-2026",
      "ambetter-formulary-2026",
      "molina-formulary-2026",
      "medicare-part-d-formulary-2026",
      "tricare-formulary-2026",
      "medicaid-drug-coverage-2026",
      "va-formulary-2026",
      "marketplace-drug-coverage-2026",
      "medicare-advantage-formulary-2026"
    ],
    "tier_systems_observed": {
      "5_tier": [
        "Aetna",
        "Cigna",
        "BCBS most plans",
        "Humana",
        "Medicare Part D standard"
      ],
      "6_tier": [
        "UnitedHealthcare",
        "Anthem"
      ],
      "4_tier": [
        "Kaiser Permanente"
      ],
      "closed_formulary": [
        "VA",
        "TRICARE"
      ]
    },
    "drug_coverage_slugs": [
      "ozempic-insurance-coverage",
      "wegovy-insurance-coverage",
      "humira-insurance-coverage",
      "eliquis-insurance-coverage",
      "jardiance-insurance-coverage",
      "mounjaro-insurance-coverage",
      "dupixent-insurance-coverage",
      "xarelto-insurance-coverage",
      "entresto-insurance-coverage",
      "keytruda-insurance-coverage",
      "insulin-insurance-coverage",
      "adderall-insurance-coverage",
      "vyvanse-insurance-coverage",
      "zepbound-insurance-coverage",
      "metformin-insurance-coverage",
      "atorvastatin-insurance-coverage",
      "levothyroxine-insurance-coverage",
      "gabapentin-insurance-coverage",
      "lisinopril-insurance-coverage",
      "omeprazole-insurance-coverage",
      "sertraline-insurance-coverage",
      "amoxicillin-insurance-coverage",
      "birth-control-insurance-coverage",
      "testosterone-insurance-coverage",
      "suboxone-insurance-coverage"
    ]
  },
  "cross_tabulation": {
    "description": "Drugs appearing in BOTH the interaction database AND the drug-coverage formulary records. These are high-risk-high-cost drugs where coverage variance compounds clinical risk.",
    "drugs": [
      "Ozempic",
      "Insulin",
      "Adderall",
      "Metformin",
      "Atorvastatin",
      "Levothyroxine",
      "Gabapentin",
      "Lisinopril",
      "Omeprazole",
      "Sertraline",
      "Amoxicillin",
      "Birth control"
    ],
    "match_count": 12,
    "match_share_of_drug_coverage_pct": 48
  },
  "headline_findings": {
    "F1_severe_interaction_share": "49.1% of cataloged interactions (26 of 53) are graded Severe.",
    "F2_top_offender_ibuprofen": "Ibuprofen appears in 10 of 53 interactions (18.9%), the most of any single drug.",
    "F3_pap_modal_income_floor": "43.6% of PAPs (24 of 55) cap eligibility at 400% of the Federal Poverty Level.",
    "F4_manufacturer_dominance": "65.5% of PAPs (36 of 55) are manufacturer-run rather than independent nonprofit.",
    "F5_tier_system_variance": "Insurers run formularies on three different tier counts (4-, 5-, and 6-tier) plus closed formularies, making cross-plan comparison non-trivial.",
    "F6_cross_tab": "12 drugs (48% of OmniRx drug-coverage entries) overlap the interaction catalog, concentrating clinical risk and pricing variance on the same set of medications.",
    "F7_glp1_concentration": "Five of the 25 drug-coverage entries (20%) are GLP-1 or weight-loss drugs (Ozempic, Wegovy, Mounjaro, Zepbound, plus the diabetes-coded indications), reflecting the 2024-2026 demand surge.",
    "F8_pap_drug_concentration": "Eliquis and Jardiance are each covered by 4 different PAPs, the modal high-overlap pattern.",
    "F9_severity_skew": "Severe + Moderate together account for 79.2% of interactions (42 of 53)."
  },
  "methodology_notes": [
    "All three datasets are first-party OmniRx editorial records. Interaction descriptions and mechanisms are sourced from FDA, NIH/PubMed, and peer-reviewed pharmacology literature. Editorial review by a credentialed clinician is pending.",
    "Drug-coverage entries summarize publicly disclosed insurer formularies as of Q2 2026. Tier placement varies by plan, region, and effective date; this dataset captures the most-common-tier placement at the parent-insurer level.",
    "PAP eligibility income limits are normalized to percent-of-Federal-Poverty-Level where the source program publishes that ratio. Where only a flat dollar figure is published, we map it to the closest FPL bracket for an individual filer using the 2025 HHS poverty guidelines.",
    "Cross-tabulation between interaction-drugs and drug-coverage-drugs uses case-insensitive substring matching against slugs. Brand-name and generic alignment is manual where the slug uses one form and the interaction record uses the other.",
    "All counts are reproducible by running aggregation against the source JSON in the OmniRx repository."
  ],
  "data_gaps": [
    "Interaction count of 53 is not yet at the 100+ threshold needed for category-level severity statistics with tight confidence intervals.",
    "Insurer formulary records describe tier-system structure but do not yet enumerate per-drug tier placement at scale; the 3x patient-pays-more finding is supported by qualitative drug-coverage entries rather than a full quantitative cross-plan tier matrix.",
    "PAP enrollment and approval-rate data is not publicly disclosed by manufacturers and is not in this dataset.",
    "PBM rebate retention data referenced from the FTC interim reports is summarized at the industry level, not at the per-drug or per-plan level."
  ],
  "medical_disclaimer": "This research is for informational purposes. Drug pricing data reflects publicly disclosed formulary information; individual experience varies by plan, region, and effective date. Consult your pharmacist or physician for personalized guidance. Drug interaction data is editorially curated and pending clinical review; do not change or stop a prescribed medication based on this dataset.",
  "metadata": {
    "dataProvenance": "SOURCED: cross-references first-party OmniRx datasets (compiled + maintained at omnirx.org), with clinical/severity fields graded per DailyMed, FDA labeling, and peer-reviewed pharmacology (PubMed); spread-pricing figures drawn from public drug-pricing references. See the study's Methodology section for the full per-field source list. DERIVED: the spread/markup aggregates. Informational only — NOT medical or financial advice."
  }
}