According to a recent report from the House Committee on Oversight and Accountability, pharmacy-benefit managers (PBMs) are directing patients towards higher-priced medications while simultaneously limiting their options for where to obtain prescriptions. This report follows an extensive 32-month investigation and is timed with an impending hearing involving executives from the leading PBM organizations in the United States.
PBMs act as intermediaries for prescription drug plans, negotiating prices between health insurers and pharmaceutical companies. They also determine the out-of-pocket costs that patients face when filling prescriptions. The three largest PBMs—Express Scripts, OptumRx (a subsidiary of UnitedHealth Group), and Caremark (part of CVS Health)—together manage around 80% of prescriptions dispensed in the U.S.
The committee’s findings indicate that PBMs tend to develop preferred drug lists that prioritize higher-cost brand-name drugs over more affordable alternatives. For example, staff emails from Cigna reflected a discouragement of using cheaper substitutes for Humira, a common treatment for arthritis priced at about $90,000 annually, despite the existence of biosimilars available for roughly half that cost.
Additionally, the report highlighted practices wherein Express Scripts informed patients that they would incur higher costs at local pharmacies compared to filling prescriptions through their associated mail-order services. This practice may restrict patient autonomy in choosing their pharmacies.
In a related note, the U.S. Federal Trade Commission (FTC) released a report suggesting that the dominance of the six largest PBMs allows them to control nearly 95% of all prescriptions in the U.S. The FTC’s findings raise concerns about PBMs exerting significant influence over patient access and affordability of medications, leading to potential conflicts of interest that could disadvantage independent pharmacies and inflate overall drug costs.
FTC Chair Lina M. Khan emphasized that these intermediaries are reportedly overcharging patients for critical medications, including cancer treatments, generating more than $1 billion in revenue from these practices.
While these findings are alarming, they shed light on the ongoing discussions about reforming the PBM industry. There is hope that increased scrutiny and potential legislative action could lead to fairer pricing strategies that prioritize patient welfare and ensure broader access to necessary medications. As the landscape of prescription drug management evolves, it offers an opportunity for stakeholders to advocate for more transparent and equitable practices in the healthcare system.