A recent report by the House Committee on Oversight and Accountability accuses pharmacy-benefit managers (PBMs) of directing patients toward more costly medications while restricting their options for obtaining these drugs. This report follows a 32-month investigation and is set for discussion in a hearing involving executives from the nation’s top PBMs.
PBMs serve as third-party administrators for prescription drug plans under health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket expenses. The three largest PBMs in the U.S. – Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark – collectively manage roughly 80% of the country’s prescriptions.
The findings indicate that these PBMs maintain lists of preferred drugs that often favor more expensive brand-name medications over their cheaper alternatives. For instance, the report highlights communications from Cigna’s staff encouraging avoidance of less expensive options for Humira, a treatment for arthritis, despite the existence of a biosimilar that costs half the price.
Moreover, it was discovered that Express Scripts informed patients that filling prescriptions at local pharmacies would likely incur higher costs than obtaining a three-month supply from its associated mail-order pharmacy, thereby restricting patient choice.
Concurrently, the U.S. Federal Trade Commission (FTC) released a report stating that increased consolidation among PBMs has resulted in six major players controlling nearly 95% of prescriptions in the U.S. The FTC expressed concern over the substantial power PBMs wield over access to and affordability of prescription medications, noting the potential conflict of interest created when PBMs favor their own affiliated businesses.
FTC Chair Lina M. Khan emphasized that the intermediaries are “overcharging patients for cancer drugs,” leading to an additional revenue stream exceeding $1 billion.