A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications and restricting their pharmacy options. This report, which follows a 32-month investigation, comes ahead of a hearing featuring executives from the nation’s largest PBMs.
PBMs serve as intermediaries for prescription drug plans and negotiate prices with pharmaceutical companies on behalf of health insurers. They also establish out-of-pocket expenses for patients. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of prescriptions.
The committee’s findings indicate that PBMs prefer to include higher-priced brand-name drugs on their lists, rather than cheaper alternatives. An example highlighted is the case of Humira, an arthritis treatment priced at $90,000 annually, while at least one biosimilar is available for half that cost. Emails from Cigna staff were cited, revealing efforts to deter patients from opting for these less expensive alternatives.
Additionally, the committee found that Express Scripts informed patients they would incur higher costs filling prescriptions at their local pharmacies compared to acquiring a three-month supply through its mail-order service, thereby limiting patient pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a report echoing similar concerns, noting that the increasing consolidation among the six largest PBMs allows them to manage nearly 95% of all prescriptions in the country. The FTC warned that this dominance grants the leading PBMs significant power over patients’ access to and affordability of prescription medications. The report suggests that vertically integrated PBMs often prioritize their affiliated businesses, leading to conflicts of interest that disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen are reportedly overcharging patients for cancer treatments, generating more than $1 billion in additional revenue.