A new report from the House Committee on Oversight and Accountability accuses pharmacy-benefit managers (PBMs) of directing patients toward costlier medications while restricting their pharmacy options. This comes after a thorough 32-month investigation leading to an upcoming hearing featuring executives from the country’s largest PBMs.
PBMs serve as intermediaries between health insurers and pharmaceutical companies, negotiating drug prices and determining patients’ out-of-pocket costs. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of the prescription market in the United States.
The committee’s findings indicate that these PBMs maintain lists favoring expensive brand-name drugs over lower-cost alternatives. For instance, internal communications from Cigna dissuaded the use of a more affordable biosimilar for Humira, a medication priced at about $90,000 annually, despite the biosimilar costing half that amount.
Additionally, Express Scripts has reportedly informed patients that they may pay more at local pharmacies than through their associated mail-order service, further restricting consumer choice regarding where to get their prescriptions filled.
This situation has drawn parallels to a recent report by the U.S. Federal Trade Commission, which noted that the increased concentration among major PBMs allows them to dominate nearly 95% of U.S. prescriptions. The FTC highlighted that the leading PBMs are undermining patients’ access to affordable medications, indicating that conflicts of interest with their affiliates might lead to higher costs for patients.
In a statement, FTC Chair Lina M. Khan emphasized that these practices were resulting in substantial overcharges for cancer drugs, providing PBMs with an additional $1 billion in revenue.
In summary, the investigation into PBMs reveals concerning practices that may hinder patients’ access to affordable medications. As this issue gains attention, there is hope that increased scrutiny may lead to reforms that improve transparency and fairness in prescription drug pricing, ultimately benefiting patients across the nation. This ongoing dialogue may help pave the way for a system where patients can more easily access necessary medications at reasonable prices.