A recent report from the House Committee on Oversight and Accountability has raised concerns about the practices of pharmacy-benefit managers (PBMs), suggesting that they are steering patients towards more expensive medications while limiting their pharmacy options. This report, which followed a comprehensive 32-month investigation, was discussed prior to a hearing featuring executives from the country’s largest PBMs.
PBMs serve as third-party administrators of prescription drug plans for health insurers, negotiating costs with pharmaceutical companies. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control approximately 80% of prescriptions in the United States.
The report indicates that PBMs have created preferred drug lists that often prioritize higher-priced brand-name medications over more affordable generic alternatives. For instance, the investigation uncovered communications from Cigna staff that dissuaded the use of a less costly alternative to Humira, an arthritis medication priced at $90,000 annually, which has a biosimilar available for half that amount.
Moreover, the report highlighted instances where Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to ordering a three-month supply through its affiliated mail-order service. This practice risks limiting patients’ choice of pharmacy.
The findings echo those of a recent U.S. Federal Trade Commission report, which noted that rising vertical integration among PBMs has led them to control nearly 95% of prescriptions filled in the country. The FTC expressed concerns about the significant influence PBMs wield over patients’ access to affordable medications. FTC Chair Lina M. Khan indicated that this increasing power can create conflicts of interest, potentially raising drug prices for consumers.
These revelations spotlight the urgent need for reform in the PBM sector, ensuring that the interests of patients and affordable access to medications are prioritized over profit-driven motives.
This situation presents an opportunity for advocacy and action. By increasing awareness and pushing for regulatory changes, there is potential for significant improvement in how patients access their medications, leading to enhanced affordability and choice in healthcare.
In summary, the findings of these investigations call attention to the pressing challenges patients face regarding prescription drug pricing and accessibility, but they also pave the way for meaningful changes in the healthcare system that could benefit millions.