A recent report released by the House Committee on Oversight and Accountability has raised significant concerns regarding the practices of pharmacy-benefit managers (PBMs), claiming that they are directing patients towards more expensive medications while restricting their pharmacy options. This document follows a thorough 32-month investigation, which coincides with an upcoming hearing featuring top executives from the country’s leading PBMs.
PBMs, which serve as third-party administrators for prescription drug plans on behalf of health insurers, are responsible for negotiating drug prices and determining the out-of-pocket expenses for patients. The report highlights that the three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of the U.S. prescription market.
According to the findings, these PBMs have been favoring costlier brand-name medications over more affordable alternatives on their preferred drug lists. For instance, emails from Cigna reportedly indicate discouragement towards opting for less expensive alternatives to Humira, a medication for arthritis and autoimmune disorders, even though a biosimilar was available for significantly less.
Moreover, the committee found that Express Scripts informed patients they would incur higher costs when using local pharmacies compared to obtaining a three-month supply from their affiliated mail-order service, effectively restricting patient choices.
The U.S. Federal Trade Commission (FTC) also recently issued a report echoing these findings. It noted that the six largest PBMs handle nearly 95% of all U.S. prescriptions and indicated that this concentration grants them overwhelming power, influencing both access to medications and their affordability. The report raised alarms over potential conflicts of interest where vertically integrated PBMs may favor their own services over those of non-affiliated pharmacies, thus increasing drug prices for consumers.
FTC Chair Lina M. Khan emphasized the findings, stating that these middlemen are substantially inflating costs for cancer medications, resulting in over $1 billion in additional revenue.
While the situation poses serious challenges for patients seeking affordable medications, it also offers an opportunity for policymakers and stakeholders to address these issues. Increased transparency in PBM practices, alongside potential reforms, could lead to improved access and affordability for prescription drugs in the future. The dialogue initiated by these reports may pave the way for significant changes that prioritize patient welfare over corporate profits.
In summary, the scrutiny on PBMs underscores the critical need to re-evaluate their role in the healthcare system, ensuring that patients’ interests remain at the forefront and that they have access to affordable and necessary medications.