Public Comments: Pharmacy Benefits Managers Workgroup Meeting One
Epic Pharmacies, Inc.
EPIC Pharmacies, Inc.
8703 Studley Rd, Suite B
Mechanicsville, VA 23116
June 1, 2026
Subject: Evidence of PBM Abuse Through Inflated Specialty Pharmacy Drug Lists
Dear Members of the Maryland PBM Workgroup,
I am submitting this letter and the attached analysis (“Specialty List Analysis CF-CRK-ESI-Optum.xlsx”) from October 2025 as evidence of systematic and widespread abuse and variability in how “specialty drug” classifications are defined and applied across both Pharmacy Benefit Managers (PBMs) and insurers operating in Maryland.
Our 2025 analysis demonstrates that major PBMs—including CVS Caremark, Express Scripts (ESI), and OptumRx—as well as insurer-developed lists (including CareFirst BlueCross BlueShield’s separate specialty drug list), are routinely classifying hundreds of non-specialty drugs as specialty medications, despite clear evidence that these drugs are readily dispensed at community retail pharmacies.
This practice artificially inflates specialty drug lists for the purpose of steering prescriptions into affiliated dispensing channels and increases costs for Maryland patients, employers, and state-funded programs.
Key Findings
Lack of Transparent or Consistent Criteria
Across all lists reviewed—both PBM and insurer-managed—there is no consistent or apparent methodology. Many drugs are generics, are stocked at retail pharmacies, and are also available through direct-to-consumer channels.
Widespread Misclassification of Non-Specialty Drugs in Commercial Networks
The dataset identifies 200+ drugs labeled as specialty by one or more PBMs or by CareFirst’s insurer-level list that should not be considered specialty. These drugs are routine oral medications, widely available at retail pharmacies, and frequently dispensed as low-cost generics.
Examples include: Capecitabine, Everolimus, Dofetilide, Cyclosporine, Tacrolimus, Darunavir and other HIV generics, Entecavir, and Droxidopa but there are many others.
NADAC Pricing Contradicts Specialty Classification
Many of these drugs have National Average Drug Acquisition Cost (NADAC) pricing, confirming they are broadly available and not subject to limited distribution, further supporting the classification of non-specialty. Examples include medications priced well below typical specialty thresholds, including drugs costing less than $1 per unit.
Systematic List Inflation Across NDCs
Entire categories of drugs—including dozens of NDCs per product—are being classified as specialty across the PBM and insurers lists. This pattern reflects systematic classification practices rather than isolated errors.
Vertical Integration Considerations
A key structural factor underlying these findings is the high degree of vertical integration within the PBM market. The three largest PBMs—CVS Caremark, Express Scripts, and OptumRx—are each owned by, or closely affiliated with, major health insurers (CVS Health/Aetna, Cigna/Express Scripts, and UnitedHealth Group/Optum, respectively). These entities also operate their own specialty pharmacies.
This integration creates inherent conflicts of interest, as the same corporate entities may control drug classification, benefit design, and dispensing channels. Without clear regulatory standards, these incentives have led to systematic expansion of specialty drug lists in ways that increase costs and limit patient choice.
The presence of similar misclassification practices across these vertically integrated organizations—as well as within insurer-developed lists such as CareFirst’s—raises important questions regarding conflicts of interest, alignment of incentives, and the need for clear regulatory guardrails to ensure that drug classification decisions are based on objective clinical criteria rather than profits for Fortune 15 companies.
Impact on Maryland Patients and Plan Sponsors
Regardless of whether classification originates with the PBM or insurer, patients face higher cost-sharing through specialty tiers than they would with a non-specialty designation. Access is restricted to specialty pharmacy networks (often affiliated with the PBM controlling the plan) and employers and fully insured plans experience inflated specialty spending. From a regulatory standpoint, consistent transparent classification results in clear benefit design, realistic cost tiering, and increased patient access to lower cost options. Patients should be able reasonably expect that a “specialty” designation reflects a clinical need and is not tied to corporate profits.
Policy Recommendations for Maryland
1. Establish a uniform, statutory definition of “specialty drug” that is not related to cost
2. Require disclosure of classification methodologies (PBMs and insurers)
3. Clarify accountability between PBMs and insurers
4. Audit both PBM and insurer-maintained specialty lists
5. Restrict specialty designation for NADAC-available retail drugs
6. Establish guardrails addressing vertically integrated steering
Conclusion
The attached analysis demonstrates that specialty drug list inflation occurs across multiple PBMs and insurers. These patterns are consistent with incentives created by vertically integrated healthcare entities to steer prescriptions and profits to their own specialty pharmacies rather than patient care.
Addressing this issue is critical to achieving transparency, cost control, fair patient access, and competitive pharmacy markets.
Thank you for your consideration of this evidence. I welcome the opportunity to discuss these findings further or support the Workgroup’s development of appropriate policy solutions.
Sincerely,
Brian M. Hose
Chief Executive Officer
EPIC Pharmacies, Inc.
Maryland Chamber of Commerce
60 West Street, Suite 100
Annapolis, MD 21401
September 4, 2026
Pharmacy Benefits Managers Workgroup
c/o Maryland Insurance Administration
200 St. Paul Place
Suite 2700
Baltimore, Maryland 21202
Dear Members of the Pharmacy Benefits Managers Workgroup,
Founded in 1968, the Maryland Chamber of Commerce (the Chamber) is the leading voice for business in Maryland. We are a statewide coalition of more than 7,000 members and federated partners working to develop and promote strong public policy that ensures sustained economic growth for Maryland businesses, employees, and families.
The Maryland Chamber of Commerce appreciates the opportunity to provide input to the Maryland Insurance Administration's (MIA) Pharmacy Benefit Manager (PBM) Workgroup. We hoped to give these comments during the August 25th meeting, but time did not allow.
As the workgroup deliberates policy recommendations over the next several meetings, it is imperative that the interests of Maryland businesses and employer-sponsored health plans remain central to the workgroup’s discussions.
Although the workgroup is not currently considering changes to the ERISA exemption under state law, the policy decisions being discussed can still have significant consequences for employers and the millions of Marylanders who receive health coverage through their employers.
Employer-Sponsored Coverage Matters
Employer-sponsored health insurance covers more than 3.2 million Marylanders, or approximately 54% of the state’s covered population. Any decision impacting prescription drug costs and health plan design have the potential to affect a significant share of Maryland families.
Prescription drug spending represents a significant and growing component of healthcare costs for employers, accounting for approximately 20–25% of total healthcare spending for employers. As prescription drug costs continue to rise, employers face increasing pressure to balance comprehensive benefits with the need to keep coverage affordable for employees and their families.
Employers pay a significant share of Maryland’s healthcare costs. When those costs increase, that pressure ultimately reaches employees through premiums, deductibles, cost-sharing, or other reductions in compensation.
Plan Sponsors Are Different
We also ask that the workgroup keep in mind that not all plan sponsors are alike. Government plans, union plans, and private employer plans have different structures, priorities, and needs. A small business in Gaithersburg may face very different challenges than a construction union in Baltimore or a large Maryland employer.
Policy decisions should account for this diversity and avoid unnecessarily increasing costs or limiting flexibility for employers and plan sponsors.
Keep Affordability at the Center
As the workgroup considers potential policy changes, we encourage members to keep two questions in mind:
Will this save money for patients and consumers in Maryland?
Will it increase costs for employers and other plan sponsors?
These questions are directly connected. Increased costs for plan sponsors ultimately have consequences for the employees and families who rely on employer-sponsored coverage.
The Maryland Chamber of Commerce appreciates the work of the PBM Workgroup and encourages members to keep Maryland businesses, plan sponsors, and the affordability of employer-sponsored healthcare at the forefront of your discussions.
Sincerely,
Mary Kane
President & CEO
Maryland Chamber of Commerce
