A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting their options for obtaining these drugs. This report follows a 32-month investigation and comes ahead of a hearing featuring executives from the nation’s largest PBMs.
PBMs act as intermediaries for prescription drug plans associated with health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—control about 80% of all prescriptions filled in the country.
The committee’s findings indicate that PBMs often create preferred drug lists that prioritize higher-priced brand-name medications over more affordable alternatives. For instance, the report references emails from Cigna that proposed discouraging the use of cheaper substitutes for Humira, an arthritis treatment that cost $90,000 annually, despite the availability of a biosimilar for half that price.
Additionally, it was reported that Express Scripts informed patients that they would face higher costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply through the mail-order service affiliated with the company. Such practices limit patient choice in selecting pharmacies.
Notably, the U.S. Federal Trade Commission (FTC) issued a related report earlier this month, highlighting how increased consolidation within the PBM industry has allowed the six largest PBMs to manage nearly 95% of prescriptions in the nation. The FTC expressed concern over the substantial influence these firms have over the accessibility and affordability of prescription medications for Americans.
According to FTC Chair Lina M. Khan, these middlemen are reportedly “overcharging patients for cancer drugs,” generating more than $1 billion in additional revenue as a result.