A recent report released by the House Committee on Oversight and Accountability has raised critical concerns regarding pharmacy-benefit managers (PBMs) and their influence on prescription drug pricing. This comprehensive investigation, spanning over 32 months, highlights practices that appear to guide patients toward costlier medications while simultaneously restricting their pharmacy choices.
PBMs act as intermediaries between health insurers and drug manufacturers, negotiating prices and determining out-of-pocket costs for patients. The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control approximately 80% of prescriptions filled nationwide.
The report indicates that these organizations are favoring certain higher-priced brand-name drugs over more affordable alternatives. As a case in point, communications from Cigna were cited, discouraging the use of a cheaper biosimilar for Humira, a drug priced at $90,000 annually. The available biosimilar offered a significantly lower price, underscoring the potential for cost savings that patients were not directed toward.
Additionally, the committee noted that Express Scripts incentivized patients to opt for three-month supplies from their mail-order service instead of filling prescriptions at local pharmacies, effectively limiting patients’ choices while also heightening their need to rely on specific PBMs.
This issue is underscored by a recent interim report from the U.S. Federal Trade Commission, which revealed that the top six PBMs are now managing nearly 95% of all prescriptions filled in the country. The FTC emphasized the troubling power these PBMs wield, stating that their operations may lead to conflicts of interest and increased drug costs, particularly harming unaffiliated pharmacies.
FTC Chair Lina M. Khan pointed out that these practices could result in patients overpaying for critical medications, notably cancer drugs, with estimates suggesting that over $1 billion in additional revenue is generated for PBMs through such tactics.
The findings of the committee and the FTC call for greater scrutiny and potential reform to ensure that patients have access to affordable medications. The increasing awareness of these issues could lead to constructive changes in the healthcare landscape, promoting fairer practices and improved affordability for patients in the long run. The ongoing attention to these matters may well help foster a system that prioritizes patient needs over corporate profit margins.