A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting their choices for obtaining prescriptions. This information comes after a 32-month investigation leading to a hearing featuring executives from major PBMs.
PBMs serve as intermediaries for health insurers in managing prescription drug plans. They negotiate pricing with drug manufacturers and determine patients’ out-of-pocket expenses. The three biggest PBMs in the U.S. — Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark — are responsible for approximately 80% of all prescriptions dispensed in the country.
According to the committee’s findings, PBMs have developed lists favoring high-priced brand-name drugs instead of offering cheaper options. The report includes examples, such as Cigna staff emails that advised against using a more affordable alternative to Humira, a medication with an annual cost of $90,000. One available biosimilar was priced at half that amount.
The investigation also noted that Express Scripts informed patients they would incur higher costs by using local pharmacies compared to ordering a three-month supply through its mail-order service, thereby restricting patients’ pharmacy choices.
Moreover, a recent report from the U.S. Federal Trade Commission corroborated these concerns, stating that the six largest PBMs manage nearly 95% of U.S. prescriptions due to increased vertical integration. The FTC’s findings highlight the considerable influence PBMs have over Americans’ access to affordable medication and raise alarms about potential conflicts of interest favoring affiliated businesses, which could disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan pointed out that these findings reveal that PBMs have been “overcharging patients for cancer drugs,” resulting in additional profits exceeding $1 billion.