A recent report from the House Committee on Oversight and Accountability has raised significant concerns about the practices of pharmacy-benefit managers (PBMs). The findings suggest that PBMs are directing patients toward more costly medications while restricting where they can obtain these prescriptions. This comprehensive study, developed over a 32-month investigation, comes ahead of an anticipated hearing featuring executives from the country’s largest PBMs.
PBMs act as intermediaries between health insurers and pharmaceutical companies, negotiating drug prices and establishing out-of-pocket expenses for patients. Notably, Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (operated by CVS Health) together manage about 80% of prescriptions filled in the United States.
According to the report, PBMs have designed lists of preferred medications that prioritize higher-priced brand-name drugs, sidelining more affordable alternatives. For instance, communications from Cigna indicated a discouragement of cheaper substitutes for Humira, a drug costing around $90,000 annually, despite the existence of a biosimilar available for approximately half the price.
Additionally, Express Scripts purportedly informed patients that filling prescriptions at local pharmacies would be costlier than obtaining a three-month supply through its affiliated mail-order service. Such practices effectively restrict patient choice regarding pharmacy options.
Supporting these findings, a recent report from the U.S. Federal Trade Commission (FTC) echoed concerns about the growing concentration and integration of PBMs, which now control nearly 95% of all prescriptions in the U.S. The FTC highlights that the dominance of these PBMs poses challenges in accessing and affording medications, suggesting potential conflicts of interest for PBMs that favor affiliated businesses over independent pharmacies.
FTC Chair Lina M. Khan stated that these findings are troubling, indicating that PBMs are significantly impacting the affordability of prescription drugs, particularly cancer medications, potentially costing patients more than $1 billion in additional charges.
This report signals a critical moment for patients and healthcare in the U.S., emphasizing the need for increased transparency and reform in the management of prescription drug costs. As awareness grows, there may be a stronger push for policies aimed at ensuring patients can access affordable medications without being steered toward more expensive options.
Overall, while the current situation is concerning, there is hope for positive change as legislators and regulatory bodies address these significant issues in the healthcare system.