A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are guiding patients toward more expensive medications and restricting their pharmacy choices. This conclusion comes after an extensive 32-month investigation that preceded a hearing featuring top executives from the major PBMs in the country.
PBMs serve as intermediaries for prescription drug plans provided by health insurers, negotiating prices with pharmaceutical companies and establishing out-of-pocket costs for patients. The biggest players in this industry—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of U.S. prescriptions.
The committee’s report highlights concerning practices among PBMs, such as the creation of preferred drug lists that favor higher-priced brand-name drugs over lower-cost alternatives. An example cited involves Cigna, which reportedly discouraged the use of a less expensive biosimilar for Humira, a costly arthritis treatment priced at $90,000 annually. It was noted that another option existed for half that price.
Additionally, the investigation found that Express Scripts advised patients that prescriptions filled at local pharmacies would cost more than obtaining a three-month supply from its affiliated mail-order service, thus limiting patient choice in selecting their pharmacy.
The findings align with recent observations from the U.S. Federal Trade Commission (FTC), which stated that the six largest PBMs manage nearly 95% of all filled prescriptions in the country. The FTC’s report raised alarms over the significant power these PBMs exert on patients’ access to affordable medications. It suggested they may prioritize their own businesses, creating conflicts of interest that disadvantage independent pharmacies and inflate drug costs. According to FTC Chair Lina M. Khan, these practices have led to overcharging patients for prescription drugs, particularly cancer treatments, generating over $1 billion in additional revenue for these middlemen.
This situation reflects a broader challenge within the healthcare system, but it also opens avenues for reform and greater transparency. Stakeholders are increasingly aware of these issues, which could lead to regulatory changes aimed at prioritizing patient care and lowering drug costs. As discussions continue, there is hope for a healthcare landscape that favors patient access and affordability over profit margins.