A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while simultaneously restricting their pharmacy choices. The findings follow a comprehensive 32-month investigation into the operations of these entities, which play a vital role in managing prescription drug plans for health insurers.
PBMs, which include major players like Express Scripts, OptumRx, and Caremark, control around 80% of prescriptions dispensed in the United States. These organizations negotiate drug prices with pharmaceutical companies and determine patients’ out-of-pocket expenses.
The committee’s study uncovered concerning practices, including the establishment of drug formularies that prioritize more expensive branded medications over affordable alternatives. A striking example highlighted in the report is Cigna’s discouragement of using lower-cost alternatives to Humira, a drug for arthritis, which costs about $90,000 per year despite the availability of biosimilars priced at approximately half that.
Moreover, the report indicates that Express Scripts informed patients they would incur higher costs when filling prescriptions at local pharmacies compared to using their affiliated mail-order service, thereby limiting patient choice.
These concerns echo findings from a recent Federal Trade Commission (FTC) report, which pointed out that consolidation and vertical integration among the largest PBMs are enabling them to manage nearly 95% of filled prescriptions in the U.S. The FTC’s interim report suggested that these practices lead PBMs to prioritize their own affiliated businesses, resulting in potential conflicts of interest that can hinder competition and inflate drug prices for consumers.
FTC Chair Lina M. Khan emphasized the troubling implications of these findings, particularly pointing out that consumers are being overcharged for essential medications, with some PBMs allegedly generating excess revenues exceeding $1 billion from cancer drug sales alone.
While the situation appears dire, the increased scrutiny from governmental bodies like the House Committee and the FTC highlights an opportunity for reform. By addressing the challenges posed by PBMs, there is hope for fostering a more equitable pricing structure in the healthcare system. This scrutiny can lead to greater transparency and potentially prompt legislative changes that would allow patients access to more affordable medications and better choices.
In summary, the ongoing investigation into PBMs reveals significant challenges regarding drug pricing and patient access, but it also paves the way for vital reforms that could enhance the way medications are administered and financed in the future.