A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their access to cheaper alternatives. This finding is part of a comprehensive investigation that has lasted 32 months, and it precedes an upcoming hearing involving executives from the major PBM companies.
PBMs, which serve as intermediaries managing prescription drug plans for health insurers, negotiate drug prices with pharmaceutical firms and determine out-of-pocket expenses for patients. The three largest PBMs in the United States—Express Scripts, OptumRx (UnitedHealth Group), and Caremark (CVS Health)—control approximately 80% of all prescriptions filled across the nation.
The committee’s investigation uncovered that PBMs have a tendency to favor expensive brand-name drugs over more affordable options. Specific evidence cited in the report includes emails from Cigna staff dissuading the use of cheaper substitutes for Humira, an arthritis medication priced at around $90,000 annually, despite the availability of a biosimilar at roughly half that cost.
Moreover, Express Scripts reportedly communicated to patients that they would incur higher charges by filling prescriptions at local pharmacies compared to receiving a three-month supply from its affiliated mail-order service. Such practices effectively limit patients’ choices of pharmacies.
Adding to these concerns, the U.S. Federal Trade Commission (FTC) released a related report stating that the increasing consolidation among PBMs now allows the six largest entities to manage nearly 95% of all prescriptions fulfilled in the country. The FTC voiced that the dominance of these PBMs grants them substantial control over the accessibility and affordability of prescription medications for Americans.
FTC Chair Lina M. Khan highlighted these findings, stating that these middlemen are allegedly overcharging patients for critical cancer medications, resulting in additional revenues exceeding $1 billion.
As the healthcare landscape continues to evolve, there remains hope for reform that promotes greater transparency and patient access to affordable medications. Increased advocacy and awareness surrounding the role of PBMs could encourage consumers to demand more equitable practices, ultimately leading to healthier outcomes for the public.