Pharmacy-benefit managers (PBMs) are reportedly guiding patients towards more expensive medications while restricting their pharmacy options, as revealed in a recent report by the House Committee on Oversight and Accountability. This report stems from a 32-month investigation by the committee and precedes a hearing featuring executives from the country’s largest PBMs.
PBMs serve as intermediaries that manage prescription drug plans for health insurers, negotiating medication prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three top PBMs, Express Scripts, OptumRx (a subsidiary of UnitedHealth Group), and Caremark (part of CVS Health), control around 80% of prescriptions in the United States.
The findings indicate that these managers have developed lists prioritizing pricier brand-name drugs over less expensive alternatives. For instance, emails from Cigna employees discouraged considering cheaper options for Humira, an arthritis treatment priced at $90,000 annually, although a biosimilar was available for approximately half that amount.
Additionally, the report highlighted that Express Scripts informed patients they would incur higher costs at local pharmacies compared to the prices available through its own mail-order service, thus limiting patients’ choices for filling prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a related report stating that increasing consolidation has allowed the six biggest PBMs to handle nearly 95% of all U.S. prescriptions. The FTC expressed concern about the significant influence these leading PBMs have over Americans’ access to affordable medications. It noted that this can lead to a conflict of interest where PBMs favor their own affiliated businesses, potentially disadvantaging independent pharmacies and driving up drug prices.
FTC Chair Lina M. Khan remarked that these findings indicate that PBMs are “overcharging patients for cancer medications,” generating over $1 billion in additional revenue as a result.