1. Manufacturer
The manufacturer sets the list price of a prescription drug. The list price is set generally higher than the actual price for payers that include hospitals, health insurers, pharmacies etc. depending on their deemed "decent" returns.
2. Middlemen
These are the payer wholesaler and retailer pharmacies that distribute the prescription drugs from the manufacturer to the consumers. They haggle with manufacturers for more favorable formulary placements. They add on the list price for profit.
3. Government
The United States Government leaves the pricing up to the market competition. It does not directly or indirectly control medicine costs. This gives the businesses opportunity to set high costs, taking advantage of the consumers' need for the prescription drugs.