Pharmacy benefit managers (PBMs) are directing patients towards pricier medications and limiting their pharmacy options, as highlighted in a report by the House Committee on Oversight and Accountability. The report, based on a 32-month investigation, precedes a hearing featuring executives from the major PBMs in the U.S.
PBMs function as intermediaries between health insurers and drug manufacturers, determining the costs that plans pay for medications and dictating what out-of-pocket expenses patients face. The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—manage approximately 80% of prescriptions in the country.
The committee’s findings reveal that PBMs prioritize more expensive brand-name drugs over affordable alternatives in their preferred drug lists. An example cited is an internal communication from Cigna, which discouraged the use of cost-effective substitutes for Humira, a treatment at the time costing $90,000 annually, despite the existence of a biosimilar priced at half that amount.
Additionally, Express Scripts was reported to inform patients that filling their prescriptions at local pharmacies would be more expensive compared to obtaining a three-month supply through their mail-order service, thereby limiting customer choice.
The U.S. Federal Trade Commission (FTC) recently echoed these concerns, releasing a report indicating that the six largest PBMs now manage nearly 95% of prescriptions in the country, raising alarms about their growing influence over prescription drug accessibility and affordability.
The FTC’s findings are concerning, stating that the leading PBMs significantly impact Americans’ access to affordable medications. Their structure creates a scenario where vertically integrated PBMs may favor their own associated businesses, which can disadvantage independent pharmacies and lead to increased drug prices. FTC Chair Lina M. Khan noted that these middlemen are overcharging patients for cancer medications, generating more than $1 billion in additional revenue.
In summary, the growing power of PBMs raises important questions about their role in the prescription drug market and its implications for consumers. However, increased scrutiny by government bodies like the House Committee and the FTC could lead to necessary reforms, aiming to enhance transparency and ultimately lower medication costs for patients, fostering a more equitable healthcare system. This awareness provides hope that change is on the horizon for a more patient-centered approach in the pharmaceutical industry.