A recent report from the House Committee on Oversight and Accountability indicates that pharmacy-benefit managers (PBMs) may be directing patients toward higher-priced medications while restricting access to them. This report follows a 32-month investigation and precedes a hearing involving top executives from the country’s major PBMs.
PBMs serve as third-party administrators for prescription drug plans offered by health insurers. They negotiate pricing with pharmaceutical companies 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—handle roughly 80% of all U.S. prescriptions.
The committee’s findings suggest that PBMs often favor expensive brand-name drugs over more affordable alternatives. Citing internal communications from Cigna, the report highlights a discouragement of cheaper alternatives to Humira, an arthritis treatment priced at $90,000 annually, despite the availability of biosimilars that cost about half that amount.
Furthermore, the report states that Express Scripts informed patients that they would pay more out-of-pocket at local pharmacies compared to obtaining a three-month supply through its own mail-order service, thus restricting patient choice in pharmacy options.
A similar report from the U.S. Federal Trade Commission (FTC) released earlier this month noted that the largest six PBMs control nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern about the significant power these PBMs wield in determining access to and affordability of prescription drugs, warning that their integrated business models could lead to conflicts of interest.
FTC Chair Lina M. Khan highlighted that the findings suggest PBMs are overcharging patients for cancer medications, generating over $1 billion in additional revenue.