A recent report from the House Committee on Oversight and Accountability indicates that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications while restricting their choices regarding where to obtain them. The investigation, which spanned 32 months, precedes a committee hearing featuring executives from the largest PBMs in the country.
PBMs serve as intermediaries for health insurers managing prescription drug plans. They negotiate drug prices with pharmaceutical companies and determine patients’ out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—handle nearly 80% of all prescriptions in the country.
The committee’s findings suggest that these PBMs have curated lists of preferred medications that consist mainly of higher-priced brand-name drugs, often disregarding less expensive alternatives. Notably, the report references internal communications from Cigna that discouraged the use of cheaper substitutes for Humira, an arthritis treatment priced at around $90,000 annually, despite the availability of a less costly biosimilar.
Additionally, the committee discovered that Express Scripts informed patients they could incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from their affiliated mail-order service. This practice effectively restricts patient choice in selecting a pharmacy.
A similar report from the U.S. Federal Trade Commission (FTC) released earlier this month highlighted significant concentration within the PBM sector, noting that the six largest PBMs now regulate nearly 95% of all prescriptions filled in the U.S. The FTC’s findings raised concerns about the power that leading PBMs wield over Americans’ access to affordable prescription drugs, suggesting that vertically integrated PBMs might prefer their affiliated businesses, resulting in conflicts of interest that disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan emphasized that the data indicates these intermediaries are “overcharging patients for cancer drugs,” enriching themselves by over $1 billion.