A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their options for obtaining them. This report follows a 32-month investigation and precedes a hearing with executives from the country’s largest PBMs.
PBMs serve as intermediaries between pharmaceutical companies and health insurers, negotiating prices and determining the out-of-pocket expenses patients face. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control approximately 80% of prescriptions.
The committee’s findings suggest that these PBMs favor higher-priced brand-name drugs over less expensive alternatives. An example highlighted in the report involves communications from Cigna staff discouraging the use of cheaper options to Humira, a drug for autoimmune conditions priced at $90,000 per year, despite the availability of a biosimilar at half that cost.
Furthermore, the report indicates that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies rather than through its own mail-order service, effectively limiting patients’ pharmacy choices.
In a related study, the U.S. Federal Trade Commission (FTC) reported that increased consolidation has allowed the six largest PBMs to oversee nearly 95% of all U.S. prescriptions. The FTC’s findings raise concerns about the significant influence these PBMs exert over access to and affordability of prescription drugs, creating potential conflicts of interest that may disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan stated that the middlemen are reportedly overcharging patients for cancer drugs, generating over $1 billion in additional revenue for the PBMs.