A recent report from the House Committee on Oversight and Accountability highlights the controversial practices of pharmacy-benefit managers (PBMs), indicating that they are steering patients towards more expensive medications and limiting their options for obtaining these drugs.
This report, which follows a lengthy 32-month investigation, precedes a hearing involving executives from the major PBMs in the country, as covered by the Wall Street Journal.
PBMs serve as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket costs for patients. The three largest PBMs in the U.S., including Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark, manage around 80% of all prescriptions.
The committee’s findings suggest that these PBMs have developed preferred drug lists that favor higher-priced brand medications over more affordable alternatives. For instance, the report cites internal communications from Cigna discouraging the use of less expensive substitutes for Humira, a treatment for arthritis that cost around $90,000 annually, despite the availability of biosimilars for half the price.
Additionally, the committee noted that Express Scripts informed patients they would incur higher costs for prescriptions filled at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, effectively restricting patient choice in pharmacy selection.
Supporting these concerns, the U.S. Federal Trade Commission (FTC) released a similar report earlier this month, indicating that increasing consolidation among PBMs has allowed the six largest firms to control nearly 95% of all prescriptions filled in the U.S. The FTC’s interim report described the significant influence of leading PBMs on Americans’ access to affordable medications, pointing to potential conflicts of interest that may disadvantage independent pharmacies and elevate drug prices.
FTC Chair Lina M. Khan commented that these findings show how PBMs are “overcharging patients for cancer drugs,” contributing to over $1 billion in additional revenue.