A recent report from the House Committee on Oversight and Accountability highlights concerning practices by pharmacy-benefit managers (PBMs), which are intermediaries between health insurers and pharmaceutical companies. The investigation, lasting 32 months, revealed that these managers often direct patients toward pricier medications while limiting their options for pharmacies.
PBMs are responsible for managing prescription drug plans, negotiating prices with drug manufacturers, and determining patient out-of-pocket costs. The report indicates that the three largest PBMs—Express Scripts, OptumRx, and Caremark—control about 80% of U.S. prescriptions, leading to significant influence over drug pricing and availability.
Notably, the report cites internal communications from Cigna that discouraged using lower-cost alternatives to high-priced drugs, such as Humira, which costs $90,000 annually, despite the availability of biosimilars at half that price. Additionally, Express Scripts allegedly informed patients that filling prescriptions at local pharmacies would lead to higher costs compared to ordering through their affiliated mail-order service, effectively restricting patients’ choices.
The findings align with a recent report from the U.S. Federal Trade Commission (FTC), which indicated that increased consolidation among PBMs has allowed them to manage nearly 95% of all prescriptions in the country. The FTC’s analysis suggests that this concentration grants PBMs undue power over prescription access and pricing, raising concerns about potential conflicts of interest as they may favor their own affiliated businesses.
The situation is alarming, with FTC Chair Lina M. Khan stating that these middlemen are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.
As the dialogue surrounding healthcare costs intensifies, there is hope that increasing awareness of these practices will lead to reforms aimed at improving patient access to affordable medications. Advocates for healthcare reform could leverage this report’s findings to push for greater transparency and competition within the pharmaceutical system, ultimately benefiting patients across the country.