A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications while restricting their choices of pharmacies. This report follows a 32-month investigation conducted by the committee prior to a hearing involving top executives from the largest PBMs in the country.
PBMs act as intermediaries for health insurers by administering prescription drug plans and negotiating prices with pharmaceutical companies. They also determine out-of-pocket costs for patients. The three biggest PBMs in the U.S.—Express Scripts, OptumRx, and Caremark—manage about 80% of all prescriptions.
According to the committee’s findings, PBMs prioritize higher-priced brand-name drugs on their preferred drug lists over more affordable alternatives. The report highlights emails from Cigna that discouraged the use of less expensive treatments for Humira, an arthritis and autoimmune condition medication that costs around $90,000 annually, despite the availability of a biosimilar for half that price.
Additionally, the committee noted that Express Scripts informed patients they would incur higher costs if they filled prescriptions at local pharmacies compared to ordering a three-month supply through its affiliated mail-order service, thereby limiting patient choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that increasing vertical integration among PBMs has allowed the six largest firms to control nearly 95% of all prescriptions in the U.S. The FTC’s findings highlighted the troubling influence PBMs have on the accessibility and affordability of medications, indicating that the leading PBMs possess substantial power over consumers’ access to prescription drugs. The commission warned that this situation creates conflicts of interest as vertically integrated PBMs may favor their affiliated businesses over independent pharmacies, leading to higher drug costs.
FTC Chair Lina M. Khan commented that these middlemen are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.