A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards pricier drugs and restricting their pharmacy options. The report, which followed a 32-month investigation, comes ahead of a hearing involving executives from the largest PBMs in the U.S.
PBMs serve as intermediaries for prescription drug plans, negotiating prices between health insurers and pharmaceutical companies while determining patients’ out-of-pocket costs. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage roughly 80% of prescriptions in the U.S.
The committee’s findings indicate that PBMs have compiled lists of preferred medications that tend to favor more expensive brand-name drugs over cheaper alternatives. An example noted in the report includes Cigna discouraging the use of lower-cost alternatives to Humira, an arthritis treatment costing around $90,000 annually, despite the existence of a biosimilar available for approximately half that price.
Furthermore, the committee pointed out that Express Scripts informed patients they would incur higher costs if they filled prescriptions at local pharmacies compared to obtaining a three-month supply through its mail-order service, effectively limiting patient choice.
A similar report was released earlier this month by the U.S. Federal Trade Commission (FTC), which highlighted that the top six PBMs control almost 95% of all U.S. prescriptions. The FTC expressed concerns over the substantial influence these PBMs have on patients’ access to affordable medications. The commission noted that the vertically integrated nature of these companies could lead to conflicts of interest, potentially disadvantaging independent pharmacies and inflating drug prices.
FTC Chair Lina M. Khan emphasized that the middlemen’s practices have led to patients being overcharged for cancer medications, generating over $1 billion in additional revenue for these PBMs.