A recent report from the House Committee on Oversight and Accountability alleges that pharmacy-benefit managers (PBMs) are pushing patients towards costlier medications while restricting their pharmacy options. This report comes after a thorough 32-month investigation leading up to a hearing that involved executives from major PBMs.
PBMs serve as intermediaries that manage prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket costs for patients. The three largest PBMs in the United States—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—collectively oversee about 80% of prescription drugs filled in the country.
The committee’s findings indicate that these PBMs often promote pricier brand-name drugs on their preferred lists instead of more affordable alternatives. For instance, emails from Cigna staff discouraged the use of less expensive alternatives to Humira, a medication for arthritis and other autoimmune disorders that had a price tag of $90,000 annually, even though a biosimilar was available for around half that cost.
Furthermore, the committee discovered that Express Scripts informed patients they would incur higher costs if they filled prescriptions at their local pharmacies compared to using its own mail-order service, effectively restricting patients’ pharmacy choices.
A similar report released earlier this month by the U.S. Federal Trade Commission (FTC) noted that the largest six PBMs manage nearly 95% of prescriptions filled in the country. The FTC expressed concerns about the influence these PBMs have on accessibility and affordability of medications for Americans, stating that they create conflicts of interest, particularly with vertically integrated PBMs prioritizing their own businesses over unaffiliated pharmacies.
FTC Chair Lina M. Khan highlighted that these middlemen are significantly inflating costs for cancer drugs, which has generated over $1 billion in additional revenue for them.