A recent report from the House Committee on Oversight and Accountability highlights that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their pharmacy options.
This report follows a thorough 32-month investigation and is timed with an upcoming congressional hearing featuring executives from the largest PBM companies in the country. PBMs act as intermediaries between health insurers and pharmaceutical firms, negotiating prices for prescription drugs and determining out-of-pocket costs for patients.
The three largest PBMs—Express Scripts, OptumRx (a subsidiary of UnitedHealth Group), and Caremark (part of CVS Health)—control around 80% of all prescriptions filled in the U.S.
According to the findings, PBMs are reportedly favoring high-priced brand-name medications over lower-cost alternatives. Notably, emails from Cigna staff indicated that they discouraged patients from opting for cheaper substitutes for Humira, a drug for arthritis and other autoimmune disorders that was priced at $90,000 annually while at least one biosimilar alternative was available for half that cost.
Additionally, the committee discovered that Express Scripts informed patients that filling prescriptions at local pharmacies would be pricier than procuring a three-month medication supply from their affiliated mail-order service, which effectively restricted patient choice.
A similar report released by the U.S. Federal Trade Commission (FTC) earlier this month noted that the largest six PBMs now manage nearly 95% of all prescriptions in the nation. The FTC expressed concern over the significant influence these leading PBMs have on Americans’ access to affordable prescription drugs, suggesting that their vertical integration creates conflicts of interest that could disadvantage independent pharmacies and escalate drug costs.
FTC Chair Lina M. Khan stated that these findings indicate middlemen are overcharging patients for cancer medications, generating over $1 billion in additional revenue.