A recent report from the House Committee on Oversight and Accountability has raised concerns that pharmacy-benefit managers (PBMs) are directing patients toward higher-priced medications while restricting their choice of pharmacies. The report is the result of a 32-month investigation and will precede a hearing involving executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and establishing the out-of-pocket costs for patients. The three largest PBMs in the United States—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—control roughly 80% of U.S. prescriptions.
According to the committee’s findings, PBMs have been favoring certain higher-priced brand-name drugs over more affordable alternatives. For instance, emails from Cigna highlighted efforts to steer patients away from cheaper options for Humira, a treatment costing $90,000 annually, despite the availability of biosimilars at about half that price.
The investigation also revealed instances where Express Scripts informed patients that they would incur higher costs if they opted to fill prescriptions at local pharmacies, compared to obtaining a three-month supply through its affiliated mail-order pharmacy. This practice limits patient choices in selecting their preferred pharmacy.
The U.S. Federal Trade Commission (FTC) released a similar report earlier this month, indicating that rising vertical integration among the six largest PBMs has allowed them to oversee almost 95% of all prescriptions in the United States. The FTC concluded that this concentration of power significantly impacts patients’ access to affordable medications and poses conflicts of interest that may disadvantage independent pharmacies.
FTC Chair Lina M. Khan highlighted that these findings suggest that PBMs are inflating costs for patients, particularly with cancer medications, generating excess revenue exceeding $1 billion.