A recent report from the House Committee on Oversight and Accountability has highlighted how pharmacy-benefit managers (PBMs) are pushing patients toward more expensive medications and restricting their options on where to get these drugs.
The report, as noted by the Wall Street Journal, emerged from a 32-month investigation that led up to a hearing involving top executives from the country’s largest PBMs. These entities serve as third-party administrators for prescription drug plans and negotiate prices with pharmaceutical companies on behalf of health insurers. They also determine the out-of-pocket expenses patients face when filling prescriptions.
The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark from CVS Health—manage around 80% of all prescriptions in the country. The committee’s findings suggest that these PBMs are favoring high-priced brand-name drugs over more affordable alternatives. For instance, emails from Cigna staff discouraged the use of less expensive substitutes for Humira, a drug for arthritis and other autoimmune disorders that costs approximately $90,000 annually, despite the availability of biosimilars at about half that price.
The report also indicated that Express Scripts informed patients they would pay more for prescriptions at local pharmacies than if they ordered a three-month supply through its affiliated mail-order service, thereby limiting patient choices regarding pharmacy access.
Adding weight to these findings, the U.S. Federal Trade Commission (FTC) released a report earlier this month, stating that increased vertical integration among PBMs has allowed the six largest firms to handle nearly 95% of all U.S. prescriptions. The FTC raised concerns that these leading PBMs possess significant influence over patients’ access to affordable medications. The Commission warned that the interests of vertically integrated PBMs could conflict with those of independent pharmacies, potentially increasing prescription costs for consumers.
FTC Chair Lina M. Khan emphasized that these middlemen are overcharging patients for vital cancer medications, resulting in excess revenues exceeding $1 billion.