A recent report from the House Committee on Oversight and Accountability highlights concerns regarding pharmacy-benefit managers (PBMs), suggesting they are guiding patients towards more expensive medications and restricting their pharmacy choices.
The findings, which followed a 32-month investigation, were disclosed ahead of a hearing involving executives from the country’s largest PBMs. These third-party administrators manage prescription drug plans for insurers and negotiate pricing with pharmaceutical companies while determining out-of-pocket costs for patients.
The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—control approximately 80% of U.S. prescription volume. The report indicates that these managers have developed preferred drug lists that prioritize higher-priced brand-name drugs over cheaper alternatives.
An example cited in the report involves Cigna employees discouraging the use of lower-cost alternatives to Humira, a treatment for arthritis and autoimmune conditions priced at $90,000 annually, despite the availability of a biosimilar at half the cost.
Additionally, the report reveals that Express Scripts informed patients they would incur higher costs by using local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, thereby limiting their pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission released a similar report stating that the largest PBMs manage approximately 95% of all prescriptions filled in the country. The FTC expressed concerns about the considerable influence these PBMs hold over patients’ access to and affordability of prescription medications, as well as the potential conflicts of interest created by their vertical integration that may disadvantage independent pharmacies.
FTC Chair Lina M. Khan emphasized that the findings indicate PBMs are “overcharging patients for cancer drugs,” resulting in an additional $1 billion in revenue for these middlemen.