A recent report from the House Committee on Oversight and Accountability highlights troubling practices by pharmacy benefit managers (PBMs), suggesting they are directing patients towards more expensive medications and restricting their pharmacy options. This investigation, which spanned over two years, coincided with an upcoming hearing featuring executives from major PBMs.
PBMs play a critical role as intermediaries, managing prescription drug plans for health insurers while negotiating prices with pharmaceutical companies. They are also responsible for determining the out-of-pocket costs patients face when filling prescriptions. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (part of CVS Health)—control roughly 80% of the prescriptions filled in the U.S.
The committee’s findings revealed that PBMs maintain preferred drug lists that favor higher-priced brand-name medications over more affordable alternatives. For instance, the report points to communications from Cigna that discouraged the use of lower-cost substitutes for Humira, an arthritis medication priced at $90,000 annually, despite the availability of a biosimilar costing around half as much.
Moreover, the report indicated that Express Scripts informed patients they would pay more at local pharmacies compared to costs associated with obtaining a three-month supply via their mail-order system, thus limiting pharmacy choices for patients.
A recent report from the U.S. Federal Trade Commission echoes these concerns, noting a high concentration of power among PBMs, which now manage around 95% of all prescriptions. The FTC has warned that this concentration raises potential conflicts of interest, as these entities might favor their affiliated pharmacies at the expense of independent ones, ultimately inflating drug costs for consumers.
FTC Chair Lina M. Khan emphasized the troubling implications of these middlemen’s practices, indicating that patients, especially those needing cancer drugs, are facing overcharges that generate over $1 billion in additional revenue for these companies.
This report sheds light on a crucial issue affecting the affordability and accessibility of prescription medications for millions of Americans. It raises the importance of advocating for reforms that could promote transparency within the PBM industry and ensure that patients have access to cost-effective options. Positive changes in policies could lead to a healthcare system that prioritizes patients’ needs over profits, improving the overall landscape of pharmaceutical care in the country.