A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are guiding patients towards pricier medications and restricting their options for obtaining prescriptions. This report, which emerged after a 32-month investigation, precedes a hearing involving executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans offered by health insurers. They negotiate pricing with pharmaceutical companies and determine the out-of-pocket costs that patients must pay.
The three largest PBMs in the United States—Express Scripts, OptumRx (owned by UnitedHealth Group), and Caremark (part of CVS Health)—together manage about 80% of the nation’s prescriptions.
The committee’s findings indicate that these managers favor higher-priced branded medications over cheaper generic alternatives. For instance, the report references emails from Cigna staff discouraging the use of lower-cost substitutes for Humira, a drug for arthritis and other autoimmune disorders that was priced at $90,000 annually. At least one biosimilar option was available for half that cost.
Additionally, the committee revealed that Express Scripts informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from their mail-order pharmacy. This practice effectively limited patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report highlighting how increasing vertical integration in the industry has allowed the six largest PBMs to control nearly 95% of all prescriptions filled in the country.
The FTC’s findings are concerning, stating that leading PBMs hold substantial power over Americans’ ability to access and afford medications. They pointed out that vertically integrated PBMs may prioritize their own affiliated companies, which could lead to conflicts of interest that disadvantage independent pharmacies and raise drug prices.
FTC Chair Lina M. Khan noted that these middlemen are “overcharging patients for cancer drugs,” reportedly generating an additional $1 billion in revenue.