A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards pricier medications and limiting their pharmacy options. The findings, which emerged from a 32-month investigation, were highlighted ahead of a hearing featuring executives from the largest PBMs in the U.S.
PBMs serve as third-party administrators for prescription drug plans, negotiating prices between health insurers and pharmaceutical companies while also determining the out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—handle about 80% of prescriptions across the country.
According to the committee’s findings, PBMs are favoring higher-cost brand-name drugs in their preferred drug lists instead of offering more affordable alternatives. The report noted instances where Cigna’s staff discouraged the use of cheaper options for Humira, a costly treatment for autoimmune diseases with an annual price tag of $90,000, while a biosimilar was available for around half that amount.
Additionally, Express Scripts informed patients that they would incur higher costs if they chose to fill prescriptions at local pharmacies compared to obtaining a three-month supply through its mail-order service, restricting patients’ choice of pharmacy.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report, indicating that the top six PBMs now account for nearly 95% of all prescriptions filled in the United States. The FTC raised concerns about the growing power of these PBMs over patients’ access to affordable medications, highlighting potential conflicts of interest due to vertical integration that can harm unaffiliated pharmacies and raise drug prices.
FTC Chair Lina M. Khan pointed out that these middlemen are “overcharging patients for cancer drugs,” resulting in over $1 billion in additional revenue for them.