A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are increasingly directing patients toward more expensive medications while restricting their choices in pharmacies. This comes after a comprehensive 32-month investigation, which was timed with a hearing involving top executives from major PBM companies.
PBMs, which act as intermediaries in prescription drug plans for health insurers and determine how much they will pay for specific drugs, currently manage approximately 80% of U.S. prescriptions through the three largest companies: Express Scripts, OptumRx (a UnitedHealth Group subsidiary), and CVS Health’s Caremark.
The committee’s findings suggest that PBMs have created “preferred drug” lists that prioritize higher-priced brand-name medications instead of more affordable alternatives. A specific example noted in the report involves emails from Cigna discouraging the use of a less expensive biosimilar treatment for Humira, a drug that costs patients around $90,000 annually, while a comparable option is available for half that price.
Additionally, the report highlighted practices where PBMs advised patients that they would incur higher costs by filling prescriptions at local pharmacies compared to acquiring a three-month supply from their mail-order services, thus limiting pharmacy choice for consumers.
This situation is echoed in a recent report from the U.S. Federal Trade Commission, which remarked on the growing concentration and market power of the six largest PBMs, which now manage nearly 95% of prescriptions filled in the United States. The FTC raised concerns over vertical integration, suggesting that these PBMs have conflicts of interest that may disadvantage independent pharmacies, ultimately leading to higher drug costs for consumers.
FTC Chair Lina M. Khan emphasized that the findings indicate patients are being overcharged for essential medications, such as cancer drugs, which has generated over $1 billion in additional revenue for these intermediaries.
In conclusion, while the power and influence of PBMs are alarming, this increased scrutiny may propel necessary reforms that could enhance affordability and accessibility of prescription drugs for patients. These developments could lead to positive changes in the healthcare landscape, benefiting consumers in the long run.