A recent report from the House Committee on Oversight and Accountability raises significant concerns about pharmacy benefit managers (PBMs) and their practices, indicating that they are directing patients toward higher-priced medications while restricting their pharmacy options. This finding comes after a comprehensive 32-month analysis in advance of a hearing featuring executives from the country’s largest PBMs.
PBMs serve as intermediaries for prescription drug plans managed by health insurers, negotiating prices with pharmaceutical companies and determining what patients will pay out-of-pocket. The three largest PBMs in the United States—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (part of CVS Health)—control approximately 80% of all prescriptions filled in the U.S.
The committee’s findings highlight that these managers often promote lists of preferred drugs that prioritize expensive brand-name medications instead of cheaper alternatives. For instance, internal communications from Cigna revealed discouragement of using lower-cost alternatives to Humira, a high-priced arthritis medication costing around $90,000 annually at the time, despite the availability of biosimilars priced at roughly half that amount.
Moreover, the committee noted that Express Scripts informed patients they would face higher costs at local pharmacies compared to a three-month supply obtained via their mail-order service. This practice limits patient choice and raises questions about fair access to pharmacy services.
The U.S. Federal Trade Commission (FTC) also released a report echoing the findings, indicating that the largest six PBMs now oversee nearly 95% of all U.S. prescriptions, raising concerns about their considerable influence over drug pricing and patient accessibility. FTC Chair Lina M. Khan remarked that these intermediary companies could potentially be profiting at the expense of patients, especially in critical areas such as cancer treatment, generating excess revenue of over $1 billion.
While the current situation presents challenges for patients and the healthcare system, these findings have sparked important discussions about reforming the role of PBMs. This could pave the way for more transparent practices in drug pricing, ultimately leading to improved access and affordability for patients in need of essential medications. A collective push for change could foster a healthcare environment that prioritizes patient well-being and monetary fairness within the pharmaceutical landscape.