
Congress Probes PBM Link to Higher Drug Prices
Congressional leaders are investigating how pharmacy benefit managers determine health plan coverage and charges for medicines.
The spotlight on rising prescription drug costs also is focusing more attention on the role of drug plan middlemen in shaping patient access to and outlays for medicines drugs. Congressional leaders are investigating how pharmacy benefit managers (PBMs) determine health plan coverage and charges for medicines, as is the Federal Trade Commission (FTC). Independent pharmacists also are loudly protesting certain PBM practices, and pharma companies readily support the shift in focus toward PBM practices and away from manufacturer launch and list prices.
The Senate Commerce Committee
More recently, the House Committee on Oversight and Accountability announced a probe of the role of PBMs in pharmaceutical markets, an effort begun by Republicans and now revived by the panel’s chairman, Rep. James Comer (R-Ky). Minority Republicans
The House panel also sent letters to the Centers for Medicare and Medicaid Services (CMS), the Office of Personnel Management (OPM), and the Defense Health Agency (DHA)
The FTC is analyzing similar issues in its investigation of whether a few large PBMs exercise excessive control of the pharmaceutical market. In February 2022, the Commission announced a formal inquiry into the effects of PBM consolidation and vertical integration with large health insurance companies. The resulting volume of comments and criticisms of PBMs sent in prompted the
The stated goal for the legislators is to better understand whether PBMs actually reduce drug costs and save money for health plans and consumers by negotiating rebates and discounts with manufacturers—or if the middlemen merely pocket those savings and limit access to important medicines from firms that fail to ante up. Manufacturers support these efforts, insisting that PBM demands for rebates and discounts drive up list prices for all medicines. And while patients in covered health plans may benefit from the lower negotiated prices, higher list prices can boost their insurance premiums and copays.
PBMs are fighting back, as seen in efforts by the industry’s Pharmaceutical Care Management Association (PCMA). The industry maintains that the proposed Senate legislation would raise costs for employers and patients and do little to limit deceptive practices.
About the author
Jill Wechsler is Washington editor for BioPharm International.
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