A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are guiding patients towards higher-cost medications while restricting their access to alternative options. This finding emerges from a 32-month investigation ahead of a hearing involving leaders from the biggest PBM firms.
PBMs act as intermediaries for prescription drug plans managed by health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket expenses. The three largest PBMs in the U.S., Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health, collectively manage around 80% of prescriptions.
According to the committee’s report, these managers curate lists of preferred medications that favor expensive brand-name drugs over more affordable alternatives. For instance, the report includes correspondence from Cigna staff advising against cheaper alternatives to Humira, a costly treatment for arthritis and other autoimmune disorders priced at $90,000 annually, despite the availability of a biosimilar for about half that cost.
Additionally, Express Scripts informed patients that they would incur higher costs by filling a prescription at a local pharmacy compared to receiving a three-month supply from its affiliated mail-order service, effectively limiting patient choice in pharmacies.
This aligns with a recent report from the U.S. Federal Trade Commission (FTC), which indicated that increasing consolidation has allowed the six largest PBMs to oversee nearly 95% of all prescriptions in the country. The FTC expressed concern over the significant influence these PBMs wield over patient access and affordability, highlighting potential conflicts of interest as vertically integrated PBMs may favor their own affiliated businesses, disadvantaging independent pharmacies and raising drug costs.
FTC Chair Lina M. Khan noted the findings indicate that these intermediaries are “overcharging patients for cancer drugs,” resulting in additional revenue of over $1 billion for the PBMs.