A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards pricier medications while restricting access to them. This report follows a 32-month investigation and comes ahead of an upcoming hearing involving executives from the largest PBMs in the country.
PBMs act as third-party administrators for prescription drug plans offered by health insurers and negotiate drug prices with pharmaceutical manufacturers. They also determine the out-of-pocket costs that patients incur for medications. The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of all prescriptions filled.
The committee’s findings indicate that PBMs have curated preferred drug lists that favor higher-priced brand-name medications over more affordable alternatives. For instance, emails from Cigna staff discouraging the use of cheaper alternatives to Humira, an arthritis treatment costing approximately $90,000 annually, were highlighted in the report. At least one biosimilar for Humira was available for about half that cost.
Additionally, the committee discovered that Express Scripts informed patients that filling a prescription at their local pharmacy would cost them more than obtaining a three-month supply through its affiliated mail-order service, thereby restricting patient choices in selecting pharmacies.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, noting that the six largest PBMs manage nearly 95% of all prescriptions in the U.S. This concentration has raised concerns about access and affordability of medications for patients. The FTC stated that leading PBMs wield significant influence over Americans’ medication access, creating a conflict of interest that could disadvantage independent pharmacies and drive up drug costs.
FTC Chair Lina M. Khan emphasized that these practices result in patients being overcharged for cancer treatments, generating more than $1 billion in additional revenue for these intermediaries.