A recent report from the House Committee on Oversight and Accountability highlights that pharmacy benefit managers (PBMs) are directing patients towards pricier medications and restricting their pharmacy choices. This finding comes after a 32-month investigation leading up to a hearing involving executives from the top PBMs in the country.
PBMs serve as intermediaries for prescription drug plans and negotiate prices between health insurers and pharmaceutical companies, also determining patients’ out-of-pocket expenses. The three largest PBMs in the U.S., Express Scripts, OptumRx of UnitedHealth Group, and Caremark from CVS Health, manage about 80% of U.S. prescriptions.
The committee’s findings reveal that PBMs have established lists of preferred medications that favor higher-priced brand-name drugs over more affordable options. An example cited in the report includes internal communications from Cigna that discouraged patients from using cheaper alternatives to Humira, a costly arthritis medication priced at $90,000 annually, despite the existence of a biosimilar available for significantly less.
Additionally, the committee discovered that Express Scripts informed patients that they would incur higher costs for prescriptions filled at local pharmacies compared to ordering a three-month supply from their affiliated mail-order service, thereby restricting patient choices in pharmacy selection.
The U.S. Federal Trade Commission (FTC) released a similar report earlier this month, stating that increasing consolidation among PBMs allows the six largest firms to control nearly 95% of all filled prescriptions in the country. The FTC’s report raised concerns about the considerable influence these PBMs have over patients’ access to affordable medications, indicating that the vertically integrated structure of these companies may lead to favoritism towards their own affiliated businesses, potentially disadvantaging independent pharmacies.
FTC Chair Lina M. Khan noted that these findings demonstrate how these middlemen are overcharging patients for essential medications, particularly cancer treatments, resulting in additional earnings exceeding $1 billion.