A recent report from the House Committee on Oversight and Accountability has raised concerns about pharmacy-benefit managers (PBMs), suggesting they are directing patients towards pricier medications and restricting their pharmacy choices. This report follows a 32-month investigation and precedes a hearing involving executives from the largest PBM companies.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating pricing with pharmaceutical manufacturers and determining out-of-pocket expenses for patients. The three leading PBMs in the U.S. – Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark – collectively manage around 80% of all prescriptions.
The House committee’s investigation revealed that PBMs often compile lists of preferred medications that prioritize higher-cost brand-name drugs over more affordable alternatives. For instance, emails from Cigna staff suggested avoiding cheaper substitutes for Humira, an arthritis treatment costing about $90,000 annually, despite the availability of a biosimilar for roughly half that price.
Additionally, the report indicated that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through its mail-order service, thereby limiting patient pharmacy options.
A similar report from the U.S. Federal Trade Commission (FTC) highlighted that the six largest PBMs control nearly 95% of prescriptions in the U.S., raising concerns over their significant influence on drug access and costs. The FTC criticized the trend of vertical integration among PBMs, which can result in conflicts of interest by favoring their own businesses while disadvantaging independent pharmacies.
FTC Chair Lina M. Khan emphasized that these findings suggest PBMs are inflating costs for patients, particularly regarding cancer medications, and generating over $1 billion in additional revenue from these practices.