Pharmacy Benefit Managers Turn a Profit by Denying Access to Necessary Medications

Video (YouTube)

WASHINGTON – In a House Oversight Committee hearing, Congresswoman Ayanna Pressley (MA-07) criticized Pharmacy Benefit Manager (PBM) executives for prioritizing profits over the health and wellbeing of patients who depend on life-saving medications.

Congresswoman Pressley specifically criticized PBMs for their medical management techniques, including “prior authorization” and “step therapy,” which can delay access to necessary care and negatively affect clinical outcomes for patients.

A full transcript of her exchange with witnesses is available below and full video is available here.

Transcript: Pressley Slams Pharmacy Benefit Managers for Putting Profits Over People
House Committee on Oversight and Accountability
July 23, 2024

REP. PRESSLEY: Thank you.

Our discussion today speaks to an injustice. An injustice that many of my constituents in the Massachusetts 7^th experience daily – the high cost of life-saving prescription medication.

Pharmacy Benefit Managers – or PBMs – play an outsized role in determining coverage and costs of medication by designing lists of drugs that a health insurance plan will cover for a patient, known as formularies.

For some medications, PBM formularies require additional approval before you, a patient, can pick them up at the pharmacy. For example, “prior authorization” is a PBM power where a doctor must ask the insurance company if they can prescribe you specific medication.

And there’s so called “step therapy” that requires you to try a different medication and have a negative reaction before being prescribed the medication that your doctor recommends.

These policies are hurting people across our nation, including in my district. 

One of my constituents, a mother, shared her story of how she was forced to go through a step therapy to treat her neurological condition and saw her condition worsen as a result – to the point where she spent a year relearning how to walk.

And her story is no anomaly. Step therapy is not just ruining people’s lives, it is killing them. Families have been robbed of their loved ones due to the delays, the greed, and harmful policies of PBMs.

Mr. Joyner, CVS Caremark is one of the largest PBMs operating within my district.What do you say to my constituents who have been harmed by denying them the medical care that they need and deserve?

MR. JOYNER: Congresswoman, I don’t have the specific details of what you’re referencing, but I certainly do understand and look specifically at ways in which we can improve the prior authorization process. 

REP. PRESSLEY: Are you sorry?

MR. JOYNER: No, I think it’s — an important part of the healthcare system is to make sure that we’re looking at — our customers hold us accountable and look for … make sure we have oversight for both patient safety. They’re also focusing on ways in which we can improve adherence to the therapy because if they’re not staying on therapy obviously then there’s a….

REP. PRESSLEY: Okay, reclaiming my time. 

I wish you were sorry. You should be.

I have not heard from a single doctor who can justify the public health benefits of these health insurance policies.

According to the Federal Trade Commission, the committees responsible for determining access to medication don’t just consider clinical recommendations. PBMs also “Take into account business considerations and make formulary determinations to maximize profits.”

I will remind the witnesses that you are all under oath. My next questions will be Yes or No.

Mr. Kautzner, does Express Scripts factor in business considerations or potential profits when deciding access to prescribed medication, yes or no? And again, you’re under oath.

MR. KAUTZNER: Thank you for the question, Congresswoman. We do a clinical first approach, so all clinical evaluation is done first…

REP. PRESSLEY: Please don’t filibuster. Yes or no?

MR. KAUTZNER: … then a financial evaluation is done after that.

REP. PRESSLEY: Yes. Yes or no, for the record?

MR. KAUTZNER: Financial evaluation is included after the clinical.

REP. PRESSLEY: Mr. Joyner, does CVS Caremark factor in business considerations or potential profits when deciding access to prescribed medication, yes or no?

MR. JOYNER: Congresswoman, we have a pharmacy and therapeutics committee that assesses the clinical value of the medication… 

REP. PRESSLEY: You all are very smart. Can you just answer the question, yes or no?

MR. JOYNER: Like I said, we have a P&T committee that assesses the clinical — 

REP. PRESSLEY: Reclaiming my time. Reclaiming my time. 

Dr. Conway, does Optum Prescription factor in business considerations or potential profits when deciding access to prescribed medications? Let’s see if three will be the charm. Yes or no?

DR. CONWAY: Clinical consideration and lowest net cost to the customer, including a formulary exception process.

REP. PRESSLEY: Reclaiming my time. Well, my office has met with patients, families, providers, and community pharmacists throughout my district, from East Boston to Cambridge to Roxbury, and they all point to one conclusion: you are putting profits over people.

Your corporations are denying people access to necessary medications, preventing them from going elsewhere by forcing independent pharmacies to close their doors.

And that is why I am glad we are having today’s hearing to shine a bright light on your unethical practices and I look forward to working in Congress to rein in PBMs.

Thank you and I yield back. 

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