A recent report from the House Committee on Oversight and Accountability indicates that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while also restricting their choices of pharmacy. This report comes after a 32-month investigation preceding a hearing involving executives from major PBMs.
PBMs serve as intermediaries for health insurers’ prescription drug plans, negotiating with pharmaceutical companies on drug pricing and determining patient out-of-pocket costs. The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—are responsible for managing about 80% of prescriptions in the United States.
The findings reveal that PBMs tend to create preferred drug lists that favor pricier brand-name medications over more affordable options. For instance, the report includes communications from Cigna that recommended against cheaper alternatives to Humira, a treatment for autoimmune conditions that costs around $90,000 annually, despite the availability of a biosimilar at half the price.
Moreover, Express Scripts reportedly informed patients that they would incur higher costs at their local pharmacies compared to purchasing a three-month supply from its affiliated mail-order service. This practice potentially diminishes patient choices regarding where to obtain their medications.
In a related development, the U.S. Federal Trade Commission (FTC) released a report claiming that increased vertical integration among major PBMs has led to these companies managing nearly 95% of all prescriptions in the U.S. The FTC expressed concerns that these leading PBMs wield considerable power over patients’ access to affordable medications, fostering a system that favors their own affiliated businesses over independent pharmacies and driving up drug costs.
FTC Chair Lina M. Khan emphasized that the findings indicate that PBMs are inflating costs for patients, particularly for cancer medications, resulting in over $1 billion in extra revenue for these intermediaries.