A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are guiding patients toward more expensive medications and restricting their choice of pharmacies. This report emerges after a 32-month investigation and is timed with an upcoming hearing featuring executives from the nation’s largest PBMs.
PBMs serve as intermediaries in prescription drug plans for health insurers, negotiating costs with pharmaceutical companies and determining patient out-of-pocket expenses. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of prescriptions filled in the U.S.
The committee’s findings indicate that PBMs are favoring higher-priced brand-name drugs on their preferred drug lists, often at the expense of more affordable options. Instances are noted in the report, including emails from Cigna discouraging the use of cheaper alternatives to Humira, a medication for arthritis and other autoimmune diseases costing approximately $90,000 annually, while at least one biosimilar was available for about half that cost.
Additionally, the committee highlighted how Express Scripts informed patients that filling a prescription at a local pharmacy could be more expensive than obtaining a three-month supply through its affiliated mail-order pharmacy. This practice appears to limit patients’ choices regarding their pharmacy options.
A similar report from the U.S. Federal Trade Commission (FTC), published earlier this month, underscores these concerns, stating that the six largest PBMs have gained significant control, managing nearly 95% of all prescriptions in the nation. The FTC warns that the considerable power held by leading PBMs adversely affects patients’ access to affordable medications and leads to conflicts of interest that favor affiliated businesses over independent pharmacies.
FTC Chair Lina M. Khan remarked that these middlemen are “overcharging patients for cancer drugs” and generating over $1 billion in additional revenue from these practices.