A recent report from the House Committee on Oversight and Accountability reveals concerning practices employed by pharmacy-benefit managers (PBMs) that may be steering patients toward more expensive medications and restricting their pharmacy options. The findings were publicized following a detailed 32-month investigation that culminated in a hearing featuring the executives from the top PBMs in the country.
PBMs serve as third-party administrators for prescription drug plans associated with health insurers. They negotiate drug prices with pharmaceutical companies and set out-of-pocket costs for patients, with three major PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (a CVS Health division)—controlling about 80% of the prescriptions in the U.S.
The committee’s report highlights that PBMs are promoting lists of preferred drugs that prominently feature higher-priced brand names, often at the expense of more affordable alternatives. For instance, internal communications from Cigna discouraged the adoption of less costly alternatives to Humira, a high-cost medication for arthritis and autoimmune conditions, which had an annual price of $90,000 at that time, despite the availability of a biosimilar option at half that cost.
Furthermore, the report notes that Express Scripts informed patients they would incur higher expenses if utilizing their local pharmacy rather than opting for a three-month supply through their affiliated mail-order service. This practice essentially limits patients’ choices regarding the pharmacies they can patronize.
In a related finding, the U.S. Federal Trade Commission (FTC) highlighted similar issues in their recent report, indicating that the six largest PBMs manage nearly 95% of all prescriptions in the United States. Such dominance grants these PBMs considerable power, potentially hindering patients’ access to affordable prescription medications. FTC Chair Lina M. Khan warned of possible conflicts of interest, as these vertically integrated entities may prioritize their own affiliated businesses, adversely affecting independent pharmacies and driving up drug costs for consumers.
Despite the troubling nature of these findings, raising awareness could lead to more robust discussions surrounding healthcare practices and potential reforms. It is crucial for stakeholders—including lawmakers, healthcare providers, and consumers—to leverage this information to push for transparency, equitable pricing, and an overall improvement in how prescription drugs are managed in the U.S.