A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications and restricting their choices regarding pharmacies. This report summarizes the findings of a 32-month investigation and was released just before a scheduled hearing with executives from the country’s largest PBMs.
PBMs serve as intermediaries for health insurance companies in managing prescription drug plans. They negotiate pricing with pharmaceutical manufacturers, but they also determine the out-of-pocket expenses that patients must bear. The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—are responsible for approximately 80% of all prescriptions in the United States.
The committee’s report indicates that these PBMs have created preferred drug lists that favor higher-priced brand names over more affordable alternatives. For instance, emails from Cigna employees discouraged the use of cheaper alternatives to Humira, a medication for arthritis and other autoimmune diseases that costs about $90,000 annually, even though a biosimilar was available for roughly half that cost.
The investigation also uncovered practices where Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies rather than using their mail-order pharmacy service. This restriction limits patient choices significantly.
Additionally, the U.S. Federal Trade Commission (FTC) released a similar report, highlighting that increasing vertical integration among the largest PBMs has enabled them to control nearly 95% of all filled prescriptions in the country. These findings raise concerns about the overwhelming influence PBMs have on patients’ access to affordable medications and point to potential conflicts of interest, particularly when PBMs prefer their affiliated companies, which can disadvantage independent pharmacies and cause an increase in drug prices.
FTC Chair Lina M. Khan noted that findings indicate these intermediaries are “overcharging patients for cancer drugs,” which could lead to more than $1 billion in additional revenue for them.
This situation prompts an essential conversation about healthcare accessibility and equitable pricing in pharmaceutical distribution. As more attention is drawn to these practices, there is hope that reforms will be implemented to enhance transparency and promote fair competition in the pharmaceutical industry, ultimately benefitting patients through improved access to affordable medications.
In summary, ongoing scrutiny of PBMs may lead to necessary changes in the healthcare system that prioritize patient welfare over profits.