Millions of Americans struggle to access their medication. Now, policymakers are asking why.
The FTC’s Inquiry
An ongoing Federal Trade Commission inquiry will see the agency explore specifically how pharmacy benefit managers – middlemen who manage health plans’ prescription drug benefits – impact patient access.
Profits over patients?
Pharmacy benefit managers negotiate drug prices and develop health plans’ formularies of approved drugs. But their role has created a complicated web of rebates, loopholes and access barriers.
Major pharmacy benefit managers, some wholly owned by insurers, include CVS Caremark, Express Scripts, OptumRx and Prime Therapeutics. They receive hundreds of billions in discounts from prescription drug companies. But how much of those savings get passed on to patients? The Federal Trade Commission wants to know.
The initial inquiry began last June but has now expanded to include more organizations, targeting harmful policies and practices that protect pharmacy benefit managers’ profits at the expense of patients. Alleged practices under the inquiry include clawbacks, unfair audits of non-participating pharmacies and arbitrary pricing. Another alleged practice is that some pharmacy benefit managers offer incentives to pharmacies that are willing to exclude lower-cost alternatives that could save patients money.
Congressional Policy Reforms Could Improve Patient Access
In addition to the FTC’s inquiry, several congressional committees have announced intentions to increase oversight over pharmacy intermediaries. Proposed legislation includes:
- The Pharmacy Benefit Manager Reform Act could control pricing and increase oversight of PBMs.
- The Drug Price Transparency in Medicaid Act would lend transparency to how Medicaid payments are processed by pharmacy benefit managers.
- The Prescription Pricing for the People Act of 2023 prompts the FTC to study middlemen in the pharmacy supply chain and report back to Congress with suggestions.
- The Pharmacy Benefit Manager Transparency Act would ban “clawbacks,” a practice of demanding patient copays that exceed the price of the actual drug, among other detrimental PBM policies.
- The Pharmacy Benefit Manager Accountability Act proposes increasing transparency and documenting findings in a series of annual reports.
While not all of these measures will pass, Congress seems as ready as the Federal Trade Commission to take action to rein in pharmacy benefit manager practices that make it harder for Americans to access care.