A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications and restricting their access to pharmacies.
The findings indicate that Medicare patients could potentially save $1.5 billion on ten specific prescription drugs. The report, shared with the Wall Street Journal, emerged from a 32-month investigation by the committee and precedes a hearing featuring executives from the nation’s largest PBMs.
PBMs serve as third-party administrators for prescription drug plans, negotiating drug prices with pharmaceutical companies and setting patients’ out-of-pocket costs. The top three PBMs in the U.S.—Express Scripts, OptumRx (a part of UnitedHealth Group), and Caremark (operated by CVS Health)—account for about 80% of all prescriptions.
According to the committee’s report, PBMs tend to favor expensive brand-name drugs over more affordable alternatives. An example mentioned includes communications from Cigna discouraging the use of lower-cost substitutes for Humira, a treatment priced at approximately $90,000 annually, despite the availability of a biosimilar at half the cost.
The committee also discovered that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to acquiring a three-month supply through their affiliated mail-order service, thereby limiting patient pharmacy choices.
Additionally, a recent report from the U.S. Federal Trade Commission (FTC) echoed these concerns, noting that the six largest PBMs manage nearly 95% of all prescriptions in the U.S. The FTC expressed alarm over the considerable power these PBMs wield over Americans’ access to affordable prescription drugs, highlighting potential conflicts of interest as vertically integrated PBMs could favor their own businesses.
FTC Chair Lina M. Khan underscored the issue, stating that these middlemen appear to be overcharging patients for cancer medications, resulting in over $1 billion in additional revenue for PBMs.