A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their pharmacy options.
The investigation, which lasted 32 months, was conducted in anticipation of a hearing involving executives from the major PBMs in the United States. The report highlights that Medicare patients could potentially save around $1.5 billion on ten specific prescription drugs.
PBMs act as intermediaries for prescription drug plans managed by health insurers, negotiating prices with pharmaceutical companies and establishing out-of-pocket costs for patients. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (a CVS Health company)—are responsible for managing approximately 80% of prescriptions filled in the United States.
The findings from the committee indicate that PBMs curate lists of preferred medications that favor higher-priced brand-name drugs over more affordable alternatives. For instance, the report references communications from Cigna staff discouraging the use of lower-cost alternatives to Humira, an arthritic treatment priced at about $90,000 annually, despite the availability of biosimilars at half the cost.
Moreover, Express Scripts allegedly informed patients that they would incur higher costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, thus limiting their choice of pharmacy.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a parallel report noting that the six largest PBMs control nearly 95% of all prescriptions in the U.S. This significant concentration raises concerns about patients’ access to affordable medication. The FTC stated that leading PBMs wield considerable influence over Americans’ ability to afford their prescriptions and that their integration with affiliated businesses could create conflicts of interest, disadvantageing independent pharmacies and raising drug costs.
FTC Chair Lina M. Khan emphasized that these findings suggest that PBMs are overcharging patients for cancer medications, resulting in over $1 billion in additional revenue.