A recent report from the House Committee on Oversight and Accountability reveals troubling practices by pharmacy-benefit managers (PBMs), suggesting they are directing patients towards more expensive medications and restricting their options for obtaining prescriptions. This report follows a comprehensive 32-month investigation leading up to a hearing that featured executives from the nation’s largest PBMs.
PBMs, which serve as third-party administrators for health insurers’ prescription drug plans, play a crucial role in negotiating prices with pharmaceutical companies and determining the co-pays that patients face. The three dominant PBMs in the U.S. — Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Caremark — collectively manage about 80% of the country’s prescribed medications.
The findings indicate that PBMs often curate lists favoring higher-priced brand-name drugs over more affordable alternatives. One stark example presented involved Cigna, which discouraged prescribing lower-cost substitutes for Humira, a treatment for arthritis that can cost around $90,000 annually, despite the existence of biosimilars priced at half that rate.
The report also highlights how Express Scripts informed patients that filling a prescription at a local pharmacy would result in higher out-of-pocket costs compared to utilizing its affiliated mail-order service. This practice raises concerns about limiting patient choices regarding where to obtain their medications.
Additionally, a recent interim report from the U.S. Federal Trade Commission (FTC) echoed many of these findings, stating that consolidation within the PBM industry has allowed just six major managers to oversee nearly 95% of all prescriptions in the country. The FTC highlighted that these leading PBMs wield significant authority over patients’ access to affordable medications, which can lead to conflicts of interest, particularly favoring their own affiliated companies, and resulting in inflated drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen are effectively inflating costs for cancer treatments, contributing over $1 billion in additional revenue by doing so.
These findings draw attention to a critical issue in the healthcare system, where patients may be inadvertently disadvantaged due to the choices made by PBMs. The hope is that increased scrutiny and regulatory efforts can lead to changes that prioritize patient access to affordable medications, ensuring that all individuals receive the best possible care without financial hardship.
In summary, while the current landscape of PBMs poses challenges for patients seeking affordable prescription medications, there is potential for reform within the industry that could enhance access and lower costs moving forward.