A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications and restricting their pharmacy choices. This report, which is based on a 32-month investigation, coincides with an upcoming hearing featuring executives from the largest PBMs in the country.
PBMs act as intermediaries for health insurers by managing prescription drug plans. They negotiate pricing with drug manufacturers and set out-of-pocket costs for patients. The three major PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of all prescriptions filled nationwide.
The committee’s findings indicate that PBMs have created preferred drug lists that favor high-priced brand-name drugs over lower-cost alternatives. The report highlights internal communications from Cigna that discouraged the use of more affordable alternatives to Humira, a drug for arthritis and other autoimmune diseases that costs $90,000 annually, even though a biosimilar was available for about half that price.
Furthermore, the investigation found that Express Scripts informed patients they would incur higher costs if they opted to fill prescriptions at local pharmacies compared to obtaining a three-month supply from their mail-order pharmacy. This practice restricts patient choices regarding pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) published a similar report. The FTC noted that the increasing consolidation of the PBM market has allowed the six largest PBMs to manage nearly 95% of U.S. prescriptions.
These developments have raised significant concerns. The FTC indicated that PBMs now wield considerable influence over Americans’ access to and affordability of prescription drugs. The situation has resulted in potential conflicts of interest, where vertically integrated PBMs might prioritize their own affiliated businesses, disadvantaging independent pharmacies and driving up drug costs. FTC Chair Lina M. Khan emphasized that these middlemen are allegedly “overcharging patients for cancer drugs,” increasing their profits by over $1 billion.