A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) may be directing patients toward high-cost medications while restricting their pharmacy options. This report follows an extensive 32-month investigation ahead of a hearing featuring executives from major PBMs.
PBMs function as intermediaries that manage prescription drug plans for health insurers. They negotiate prices with pharmaceutical companies and determine the out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, OptumRx (owned by UnitedHealth Group), and Caremark (part of CVS Health)—oversee approximately 80% of U.S. prescriptions.
The committee’s findings indicate that PBMs are prioritizing higher-priced branded medications over more affordable alternatives on their preferred drug lists. For instance, the report highlights that Cigna staff discouraged the use of cheaper alternatives to Humira, an expensive treatment for autoimmune diseases, even when lower-cost biosimilars were available.
Additionally, the report noted that Express Scripts informed patients they would pay more for prescriptions filled at local pharmacies compared to receiving a three-month supply via their affiliated mail-order service, thereby limiting patient choices and access to different pharmacy options.
A similar report from the U.S. Federal Trade Commission (FTC) underscored these concerns, indicating that the largest PBMs control nearly 95% of prescriptions in the country. The FTC expressed worry that this concentration of power could harm patients by potentially overcharging them for necessary medications, such as cancer drugs, generating more than $1 billion in added revenue for these middlemen.
Although the findings raise alarming issues about the power of PBMs in the healthcare system, they also highlight an urgent need for reform and transparency in prescription drug pricing. With growing scrutiny from both governmental bodies and the public, there is potential for positive change that could lead to more equitable access to affordable medications for all patients. This focus on reform could ultimately encourage the development of fairer practices that prioritize patient health and wellbeing over corporate profits.