A recent report from the House Committee on Oversight and Accountability has raised serious concerns about pharmacy-benefit managers (PBMs) and their impact on drug pricing and patient choice. The investigation, spanning 32 months, was conducted in anticipation of a hearing featuring executives from the largest PBMs in the country.
PBMs act as intermediaries between health insurers and pharmaceutical companies, negotiating the prices of prescription drugs and determining out-of-pocket costs for patients. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—are responsible for managing around 80% of U.S. prescriptions.
The committee found that these managers are creating preferred drug lists that prioritize expensive brand-name medications over cheaper alternatives. For instance, emails from Cigna were cited that discouraged using lower-cost options for Humira, a drug priced at $90,000 annually, even though a similar biosimilar could be obtained for about half that cost.
Moreover, findings indicated that Express Scripts informed patients they would face higher costs by filling prescriptions at local pharmacies compared to utilizing their affiliated mail-order service, further restricting patients’ choices.
The U.S. Federal Trade Commission (FTC) recently echoed these concerns in a report highlighting that the six largest PBMs control nearly 95% of all prescriptions in the country. The FTC noted that this concentration of power enables these PBMs to influence access to affordable medications significantly. It also identified potential conflicts of interest, as vertically integrated PBMs might favor their own affiliated companies, disadvantaging independent pharmacies and driving up drug costs.
FTC Chair Lina M. Khan highlighted alarming evidence that these intermediaries are overcharging patients for critical medications, including cancer drugs, leading to additional revenues exceeding $1 billion.
This situation underscores the pressing need for regulation and reform in the pharmacy benefit management sector to ensure patients have access to affordable medications without limitations on their choices.
In a hopeful turn of events, this scrutiny may lead to increased pressure for transparency and reforms that could ultimately benefit patients by making healthcare more affordable and accessible. Advocating for such changes could pave the way for more competition and better pricing practices in the pharmaceutical industry, ultimately improving patient outcomes and satisfaction.