A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) may be directing patients towards more expensive medications while restricting their access to affordable alternatives. This report, which emerged following a 32-month investigation, coincides with an upcoming hearing featuring executives from the largest PBMs in the country.
PBMs serve as third-party administrators for prescription drug plans offered by health insurers, negotiating drug prices with pharmaceutical companies and determining the out-of-pocket expenses patients must shoulder. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—handle around 80% of all prescriptions in the U.S.
The committee’s findings suggest that PBMs maintain lists of preferred medications that often favor higher-priced brand-name drugs over less expensive options. An example highlighted in the report involves Cigna, which reportedly discouraged the use of cheaper alternatives for Humira, a drug used to treat arthritis and other autoimmune conditions costing approximately $90,000 annually, despite the availability of a biosimilar at half that price.
Moreover, the committee discovered that Express Scripts informed patients they would incur higher costs if they filled prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service. This practice, as pointed out by the committee, restricts patients’ pharmacy choices.
The concerns raised by this report echo findings from the Federal Trade Commission (FTC), which recently indicated that an increasing concentration among PBMs allows the six largest players to oversee nearly 95% of prescriptions filled in the U.S. The FTC’s interim report highlighted that these leading PBMs wield considerable influence over patients’ access to and affordability of prescription drugs, leading to potential conflicts of interest that may disadvantage independent pharmacies and elevate drug costs.
FTC Chair Lina M. Khan stated that the evidence suggests that these intermediaries are overcharging patients for cancer medications, yielding them over $1 billion in additional revenue.