A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their options. The findings follow a 32-month investigation in anticipation of a hearing involving executives from the nation’s leading PBMs.
PBMs, which act as intermediaries for health insurers in managing prescription drug plans, negotiate prices with drug manufacturers and determine the out-of-pocket costs for patients. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of the country’s prescription drugs.
The committee’s investigation discovered that PBMs often maintain lists of preferred medications that favor higher-priced brand-name drugs over more affordable alternatives. One example highlighted was from Cigna, where staff discouraged patients from opting for cheaper alternatives to Humira, a treatment for arthritis and other autoimmune diseases that had a price tag of $90,000 annually, despite the availability of similar biosimilars costing half that.
Additionally, the report found that Express Scripts informed patients they would face higher costs when filling prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service. This practice effectively restricted patients’ choices regarding where to obtain their medications.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report, noting that an increase in vertical integration has given the six largest PBMs control over nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern that the major PBMs wield significant influence over Americans’ access to affordable medications and warned of conflicts of interest arising from PBMs favoring their own affiliated businesses, potentially leading to increased drug costs and disadvantaging independent pharmacies.
FTC Chair Lina M. Khan pointed out that these middlemen are contributing to an excessive financial burden on patients, particularly concerning cancer treatments, resulting in over $1 billion in additional revenue for the PBMs.