A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications and restricting their pharmacy options. This finding comes after a 32-month investigation by the committee, which precedes a hearing involving executives from the largest PBMs in the country.
PBMs serve as intermediaries for health insurers in managing prescription drug plans, negotiating prices with pharmaceutical companies and setting patients’ out-of-pocket costs. The largest three PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control nearly 80% of U.S. prescriptions.
The committee’s report indicates that PBMs often create preferred drug lists that favor higher-priced brand-name medications over cheaper alternatives. For instance, internal communications from Cigna revealed efforts to dissuade the use of more affordable options for Humira, a medication for autoimmune conditions costing around $90,000 annually, despite the existence of a biosimilar at half that price.
Additionally, it was found that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through its own mail-order pharmacy, thus constraining patient choice.
Earlier this month, the Federal Trade Commission (FTC) released a similar report highlighting that the largest six PBMs manage nearly 95% of all prescriptions dispensed in the U.S. The FTC expressed concern over the substantial influence these PBMs hold over American access to affordable medications, suggesting that their practices may favor affiliated businesses, potentially harming independent pharmacies and driving up drug prices.
FTC Chair Lina M. Khan emphasized that the findings illustrate how these middlemen contribute to inflated costs for cancer medications, generating over $1 billion in additional revenue at the expense of patients.