A recent investigation by the House Committee on Oversight and Accountability has raised significant concerns about the practices of pharmacy-benefit managers (PBMs), highlighting that these entities are directing patients towards more expensive medications while restricting their choice of pharmacies. This report was shared with the Wall Street Journal and arises from a lengthy 32-month inquiry conducted before an upcoming hearing featuring top executives from the largest PBM firms.
PBMs act as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket costs for patients. The three dominant PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of all U.S. prescriptions.
The investigation uncovered that PBMs have been compiling lists of preferred medications that favor higher-priced brand-name drugs over cheaper alternatives. For instance, the report revealed internal communications from Cigna which discouraged the prescription of more affordable substitutes for Humira, a costly treatment for autoimmune conditions. At the time, Humira was priced at $90,000 per year, whereas a biosimilar was available for approximately half that cost.
Moreover, the committee noted that Express Scripts informed patients that they could save money by opting for a three-month supply through its affiliated mail-order service instead of filling prescriptions at local pharmacies. This practice has restricted patients’ choices in selecting their pharmacies.
A similar report released by the U.S. Federal Trade Commission also echoed these concerns, indicating that the largest PBMs manage nearly 95% of all prescriptions in the U.S. The FTC’s findings point towards a troubling trend where leading PBMs hold significant control over patients’ access to affordable medications, raising alarms about conflicts of interest which could prioritize their affiliated businesses over patient interests. FTC Chair Lina M. Khan remarked that PBMs are allegedly overcharging patients, particularly for crucial cancer medications, accruing excess revenue exceeding $1 billion.
This situation calls for urgent reforms to ensure that patients can access the medications they need at fair prices without interference. As public awareness continues to grow around these issues, there is hope that regulatory changes can lead to increased transparency and competition among prescription drug providers, ultimately benefiting consumers and lowering medication costs.
In summary, ongoing scrutiny of the practices of pharmacy-benefit managers could pave the way for significant changes in the healthcare landscape, potentially leading to better access to affordable healthcare solutions for all Americans.