A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting their options for obtaining prescriptions. The findings emerged from a lengthy, 32-month investigation leading up to a congressional hearing on the subject, which included testimonies from executives of major PBM firms.
PBMs act as intermediaries for health insurers, negotiating drug prices with pharmaceutical companies and determining the out-of-pocket expenses that patients face. The three largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—manage about 80% of all prescriptions in the country.
The committee’s investigation uncovered practices where PBMs promote lists of preferred drugs that consist mainly of higher-cost brand-name medications rather than more affordable alternatives. For instance, the report highlighted that staff communications from Cigna discouraged the use of less expensive substitutes for Humira, a drug for arthritis and autoimmune disorders that was priced at $90,000 annually, despite the availability of a biosimilar at half that cost.
Additionally, the report stated that Express Scripts informed patients they would pay less for a three-month prescription through its affiliated mail-order service compared to their local pharmacy, effectively limiting patient choices regarding where to fill their prescriptions.
The U.S. Federal Trade Commission (FTC) recently published a similar report, indicating that the leading six PBMs manage nearly 95% of prescriptions filled nationwide. The FTC expressed concern over the significant influence PBMs have on the accessibility and affordability of medications for Americans. The investigation highlighted potential conflicts of interest, pointing out that PBMs may favor their own businesses over independent pharmacies, leading to increased drug costs for patients.
According to FTC Chair Lina M. Khan, these practices could result in patients being overcharged for vital medications, including cancer drugs, with the PBMs generating over $1 billion in additional revenue from these actions.