A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications and restricting their pharmacy options. This report comes in advance of a committee hearing featuring executives from the nation’s largest PBMs.
PBMs serve as intermediaries for prescription drug plans, negotiating with pharmaceutical companies regarding drug prices and determining patients’ out-of-pocket expenses. The three major PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of prescriptions in the United States.
The committee’s findings indicate that PBMs often promote lists of preferred drugs that favor higher-priced brand-name options instead of more economical alternatives. For example, the report highlights communications from Cigna that advised against using cheaper alternatives to Humira, a medication for arthritis and other autoimmune conditions, which was priced at $90,000 annually despite a biosimilar being available for half that cost.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies instead of utilizing their affiliated mail-order service. This practice has limited patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report stating that increasing integration among PBMs allows the six largest managers to oversee nearly 95% of all prescriptions in the country.
The FTC’s findings raise concerns about the power PBMs wield over patients’ access to affordable medications. The report highlighted a system in which PBMs may favor their own affiliated services, leading to conflicts of interest that harm independent pharmacies and elevate drug prices.
FTC Chair Lina M. Khan remarked that these middlemen are “overcharging patients for cancer drugs,” resulting in an excess revenue of more than $1 billion for them.