A recent report from the House Committee on Oversight and Accountability alleges that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting their options for obtaining these drugs. This report is based on a 32-month investigation and comes ahead of a hearing featuring executives from the largest PBMs in the country.
PBMs operate as third-party administrators of prescription drug plans for health insurers, negotiating prices with pharmaceutical companies on behalf of health plans and determining patients’ out-of-pocket expenses. The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—together control around 80% of U.S. prescriptions.
The committee’s findings indicate that PBMs are developing lists of preferred medications that favor higher-priced brand-name drugs over more affordable alternatives. For instance, the report references internal communications from Cigna that discouraged the use of cheaper alternatives to Humira, a medication for arthritis and other autoimmune conditions costing $90,000 per year, despite the availability of a biosimilar at half that price.
Additionally, the committee highlighted instances when Express Scripts informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service, thereby restricting patient choice of pharmacies.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that the six largest PBMs manage nearly 95% of all prescriptions filled in the U.S. The FTC’s interim report raised concerns about the substantial influence PBMs hold over Americans’ access to and affordability of prescription medications. The report suggests that the vertical integration of these companies creates potential conflicts of interest that could disadvantage independent pharmacies and elevate drug prices for consumers.
FTC Chair Lina M. Khan stated that the commission’s findings reveal that these intermediaries are significantly inflating costs for patients, specifically in the context of cancer drug pricing, resulting in over $1 billion in additional revenues for the PBMs.