Pharmacy benefit managers (PBMs) are directing patients towards pricier medications while restricting their pharmacy options, as revealed in a recent report from the House Committee on Oversight and Accountability.
This report, which is based on a 32-month investigation by the committee, anticipates a hearing involving top executives from major PBM companies. PBMs serve as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket costs.
The three largest PBMs in the United States—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (part of CVS Health)—control approximately 80% of all prescriptions dispensed in the country.
According to the committee’s findings, these PBMs preferentially list more expensive brand-name drugs rather than cheaper alternatives. An example cited includes emails from Cigna staff discouraging the use of less costly alternatives to Humira, an arthritis treatment that costs about $90,000 annually, despite the availability of a biosimilar at half that price.
Furthermore, Express Scripts reportedly informed patients that they would incur higher costs if they filled prescriptions at their local pharmacies compared to obtaining a three-month supply from their mail-order pharmacy, thereby limiting patient choices regarding where to access medications.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report highlighting that the six largest PBMs have consolidated their power, handling nearly 95% of all prescriptions filled in the nation. The FTC described these developments as alarming, stating that leading PBMs now hold significant influence over Americans’ ability to obtain affordable prescription medications. It mentioned that this structure could favor vertically integrated PBMs, leading to increased costs and conflicts of interest that disadvantage independent pharmacies.
FTC Chair Lina M. Khan emphasized that these findings implicate PBMs in overcharging patients for cancer medications, resulting in added revenue exceeding $1 billion.