A recent report from the House Committee on Oversight and Accountability suggests that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their pharmacy options. This report, which follows a 32-month investigation, precedes a scheduled hearing on PBMs featuring leaders from the largest management companies in the sector.
PBMs serve as intermediaries for health insurance prescription plans, negotiating prices with pharmaceutical firms and establishing out-of-pocket expenses for patients. The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—oversee nearly 80% of prescriptions filled nationwide.
According to the committee’s findings, PBMs often prioritize costlier brand-name drugs over more affordable alternatives. For instance, emails from Cigna employees were cited in the report, discouraging the use of less expensive alternatives to Humira, a drug for arthritis and autoimmune conditions that costs around $90,000 annually, even though a biosimilar was available for approximately half that price.
Additionally, Express Scripts reportedly informed patients that they would incur higher costs by using their local pharmacies compared to obtaining a three-month supply through their affiliated mail-order service. This practice effectively limits the choices available to patients regarding pharmacy selection.
The U.S. Federal Trade Commission (FTC) recently released a similar report, stating that heightened vertical integration among the six largest PBMs allows them to manage close to 95% of prescriptions filled in the country. The FTC highlighted that these leading PBMs wield significant influence over the accessibility and affordability of medications for Americans. It noted that the current system may encourage PBMs to favor their affiliated businesses, leading to potential conflicts of interest that could disadvantage independent pharmacies and raise costs for prescription drugs.
FTC Chair Lina M. Khan underscored the implications of these findings, indicating that patients are being overcharged for essential cancer drugs, resulting in over $1 billion in additional revenue for the middlemen involved.