A recent report from the House Committee on Oversight and Accountability reveals that pharmacy benefit managers (PBMs) are leading patients towards more costly medications and restricting their pharmacy options. This information follows a significant 32-month investigation conducted by the committee, which is set to hold a hearing with executives from some of the largest PBM companies.
PBMs act as intermediaries for prescription drug plans, negotiating prices with pharmaceutical companies on behalf of health insurers. They play a critical role in determining the out-of-pocket costs patients face when purchasing medications. Presently, the three major PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (a subsidiary of CVS Health)—manage roughly 80% of U.S. prescriptions.
The committee’s findings indicate that PBMs often promote lists of preferred drugs that prioritize higher-priced brand-name medications over more affordable alternatives. For instance, internal communications from Cigna discouraged the use of lower-cost substitutes for Humira, an autoimmune condition treatment priced at $90,000 annually, even though biosimilars were available for around half that price.
Moreover, Express Scripts has reportedly informed patients that obtaining a three-month supply of medication through its mail-order service would be cheaper than filling a prescription at their local pharmacy, thereby constraining patient choice.
Adding to these concerns, the U.S. Federal Trade Commission (FTC) recently published a report echoing similar findings. It noted that the increasing consolidation among PBMs has led to nearly 95% of all prescriptions being managed by the six largest firms. The FTC highlighted the significant influence these PBMs hold over drug accessibility, suggesting that they create conflicts of interest by favoring their own affiliated businesses, which can drive up prescription costs and disadvantage independent pharmacies.
FTC Chair Lina M. Khan underscored the daunting implications of these findings, indicating that PBMs may be overcharging patients for essential drugs like cancer medications, generating additional revenue exceeding $1 billion in the process.
This report brings to light significant concerns about the pricing and accessibility of medications for millions of Americans. However, it also presents an opportunity for reform, as stakeholders may be prompted to address these challenges and work towards a more equitable healthcare system that prioritizes patient affordability and access. Ultimately, increased scrutiny of PBMs could lead to enhanced transparency and competition in the pharmaceutical market, potentially benefiting consumers in the long run.