A recent report released by the House Committee on Oversight and Accountability has raised serious concerns about the practices of pharmacy-benefit managers (PBMs), suggesting that these entities are pushing patients towards costlier medications and restricting their choice of pharmacies. The findings stem from a comprehensive 32-month investigation and precede a hearing involving top executives from the nation’s largest PBMs.
PBMs operate as intermediaries for health insurers by managing prescription drug plans. Their roles include negotiating prices with pharmaceutical companies and establishing the out-of-pocket costs that patients face. The trio of largest PBMs—Express Scripts, OptumRx (a subsidiary of UnitedHealth Group), and CVS Health’s Caremark—are responsible for overseeing about 80% of all prescriptions filled in the United States.
The committee’s examination revealed that these PBMs prioritize higher-priced brand-name drugs over more affordable alternatives in their preferred drug lists. One example highlighted in the report is Cigna’s internal communications, which suggested avoiding cheaper alternatives for Humira, an arthritis treatment priced at $90,000 annually, despite available biosimilars costing approximately half that amount.
Additionally, the report noted that Express Scripts informed patients that they would incur higher costs if they chose to fill prescriptions at local pharmacies compared to receiving a three-month supply through their affiliated mail-order service. This practice limits patient options and creates an environment where choices can be dictated by the PBMs.
Compounding these issues, a recent report from the U.S. Federal Trade Commission (FTC) echoed similar sentiments, asserting that the six largest PBMs manage nearly 95% of prescriptions and highlighting concerns over vertical integration and conflicts of interest that could lead to higher drug costs and diminished access for patients.
FTC Chair Lina M. Khan emphasized that these findings indicate that PBMs are overcharging patients for crucial medications such as cancer drugs, generating excess revenue exceeding $1 billion.
These revelations spotlight a critical issue within the healthcare system, suggesting an urgent need for reform to enhance transparency and ensure patients have access to more affordable medication options. The hope is that increased scrutiny from government bodies and public awareness will drive improvements in the way PBMs operate, ultimately benefiting patients across the nation.