Pharmacy-benefit managers (PBMs) are reportedly directing patients toward costlier medications while restricting their access to pharmacies, according to a recent report from the House Committee on Oversight and Accountability.
This report, which followed a 32-month investigation, was issued ahead of a hearing involving leaders from the largest PBM companies in the nation. PBMs act as third-party administrators for prescription drug plans offered by health insurers, negotiating drug prices and determining out-of-pocket expenses for patients.
The three largest PBMs in the U.S. – Express Scripts, OptumRx, operated by UnitedHealth Group, and CVS Health’s Caremark – currently manage about 80% of all prescriptions filled in the country.
The committee’s findings indicate that PBMs tend to favor more expensive brand-name drugs in their preferred drug lists, often at the expense of cheaper alternatives. For instance, emails from Cigna staff were highlighted, revealing discouragement toward the use of lower-cost options to Humira, a treatment for arthritis and autoimmune conditions, which was priced at $90,000 annually, despite the availability of a biosimilar at approximately half that cost.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from their mail-order service, effectively limiting patients’ pharmacy options.
Earlier this month, the U.S. Federal Trade Commission released a similar report stating that the six largest PBMs now manage nearly 95% of all prescriptions in the country, a finding that raises concerns about the power PBMs hold over access to affordable medications. The FTC noted that this situation could lead to conflicts of interest, allowing vertically integrated PBMs to favor their own affiliated businesses.
FTC Chair Lina M. Khan emphasized that these practices result in higher charges for patients needing cancer medications, contributing to more than $1 billion in additional revenue for the middlemen.