A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients to more costly medications while restricting their pharmacy options. The report follows a 32-month investigation preceding a hearing featuring executives from the leading PBMs in the country.
PBMs act as intermediaries for prescription drug plans linked to health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—account for around 80% of all U.S. prescriptions.
According to the findings, these PBMs have compiled lists favoring more expensive brand-name drugs over more affordable alternatives. For instance, internal emails from Cigna were cited, which discouraged using cheaper options for Humira, a drug for arthritis and autoimmune conditions with an annual cost of $90,000, despite the availability of a biosimilar at nearly half that price.
The committee also reported that Express Scripts informed patients they would face higher costs at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, effectively limiting patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that heightened vertical integration has allowed the six largest PBMs to control nearly 95% of prescriptions filled nationwide. The FTC highlighted concerns about the significant power these PBMs have over Americans’ access to and affordability of prescription medications. This situation raises issues of potential conflicts of interest, particularly as vertically integrated PBMs may favor their own affiliated businesses, disadvantaging independent pharmacies and driving up drug costs.
FTC Chair Lina M. Khan emphasized that these middlemen are overcharging patients for cancer medications, resulting in additional revenues exceeding $1 billion.