A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications while restricting their choices of pharmacies. This report follows a 32-month inquiry and comes ahead of an upcoming hearing featuring leaders from the nation’s major PBMs.
PBMs act as intermediaries administering prescription drug plans for health insurance companies. They negotiate prices with drug manufacturers and establish out-of-pocket costs for patients. The three largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—handle about 80% of prescriptions in the country.
According to the committee’s findings, PBMs maintain lists that favor higher-priced brand-name drugs over more affordable generic options. For instance, the report highlights communications from Cigna employees that discouraged the use of cheaper alternatives to Humira, which was priced at $90,000 annually, despite the availability of a biosimilar costing around half that amount.
Moreover, the report indicates that Express Scripts informed patients that filling prescriptions at their local pharmacies would be more expensive than obtaining a three-month supply through their affiliated mail-order pharmacy, effectively limiting patient choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report noting that the six largest PBMs dominate nearly 95% of all prescriptions filled in the United States. The FTC’s report raises concerns over the substantial control PBMs hold over Americans’ access to affordable medications and highlights potential conflicts of interest arising from PBMs favoring their own affiliated businesses.
FTC Chair Lina M. Khan remarked that these findings illustrate how PBMs are overcharging patients for essential medications, including cancer treatments, potentially generating more than $1 billion in additional revenue for themselves.