According to a recently released report from the House Committee on Oversight and Accountability, pharmacy-benefit managers (PBMs) are directing patients towards higher-priced medications while restricting their pharmacy options. This revelation comes after a thorough 32-month investigation, which set the stage for an upcoming hearing featuring executives from major PBM firms.
PBMs play a key role as intermediaries that manage prescription drug plans on behalf of health insurers. They negotiate prices with pharmaceutical companies and determine the out-of-pocket costs that patients face. The three largest PBMs in the country—Express Scripts, OptumRx, and Caremark—collectively oversee approximately 80% of prescriptions filled in the U.S.
The committee’s findings indicate that PBMs often promote lists of preferred medications that include costlier brand-name drugs rather than less expensive alternatives. For instance, the report highlights communication from Cigna discouraging the use of more affordable biosimilars for Humira, an arthritis treatment with a steep annual cost of $90,000, despite there being a biosimilar option available at half that price.
Additionally, the investigation revealed that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from their mail-order services. This practice has the potential to limit patients’ freedom in choosing their pharmacies.
Backing these concerns, a recent report from the U.S. Federal Trade Commission noted that the consolidation and vertical integration of PBMs allow the top six firms to manage nearly 95% of U.S. prescriptions. The FTC highlighted how this concentration of power could impede access and affordability for American patients, fostering conflicts of interest that disadvantage independent pharmacies while inflating prescription costs.
FTC Chair Lina Khan raised alarms over these findings, stating that separated from being merely intermediaries, PBMs may be significantly impacting the costs of vital medications, including cancer drugs, to the detriment of patients, resulting in overcharge revenues exceeding $1 billion.
These revelations underscore ongoing issues within the pharmaceutical supply chain, but they also signal a potential turning point. Heightened scrutiny from lawmakers and regulatory bodies may lead to reforms aimed at increasing transparency, enhancing patient access, and ensuring that healthcare remains affordable and equitable for all. There is hope that continued advocacy and regulatory measures can improve the landscape for patients, encouraging a future where affordable access to essential medications becomes a reality.