A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards higher-priced medications while constraining their access to alternatives. This finding follows a 32-month investigation by the committee ahead of a hearing featuring top executives from the country’s leading PBM companies.
PBMs serve as third-party administrators of prescription drug plans for health insurers, negotiating prices with pharmaceutical firms and determining out-of-pocket expenses for patients. They manage around 80% of U.S. prescriptions, with Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark being the largest providers.
The report highlights that PBMs often recommend higher-priced brand-name drugs over less expensive generic options. For instance, internal emails from Cigna discouraged the use of cheaper alternatives to Humira, a medication for autoimmune conditions, despite a biosimilar being available at half the cost of the original drug.
Furthermore, the committee’s findings indicated that Express Scripts informed patients they would incur higher costs if they sought prescriptions from local pharmacies rather than obtaining a three-month supply from its affiliated mail-order service. This practice has restricted patient choices regarding where they can fill their prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report asserting that increased vertical integration among PBMs now allows six major players to manage nearly 95% of all prescriptions in the United States. The FTC expressed concerns about the significant influence PBMs have over patients’ access to affordable medications, suggesting that their operations foster conflicts of interest by favoring affiliated businesses and potentially raising drug prices.
FTC Chair Lina M. Khan emphasized that these practices result in patients being overcharged for essential medications, particularly cancer drugs, effectively yielding an additional revenue of over $1 billion for these middlemen.