A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their choices of pharmacies. This report, which emerged following a 32-month investigation, precedes a hearing involving executives from the nation’s largest PBMs.
PBMs act as intermediaries for prescription drug plans, negotiating prices with pharmaceutical companies and setting out-of-pocket costs for patients. The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of prescriptions nationwide.
The committee discovered that these PBMs have developed preferred drug lists that favor higher-priced brand-name medications over more affordable alternatives. An example highlighted in the report includes communications from Cigna staff advising against cheaper substitutes for Humira, a medication used to treat arthritis, which could cost around $90,000 annually, despite the availability of a biosimilar half that price.
Moreover, the findings indicated that Express Scripts informed patients that obtaining a prescription from their local pharmacy would be more expensive than a three-month supply via their affiliated mail-order service. This practice restricts patients’ pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that increased vertical integration has allowed the six largest PBMs to manage nearly 95% of all U.S. prescriptions. The FTC expressed concern that these PBMs wield significant power over Americans’ access to and affordability of prescription medications, creating a scenario where insider affiliations can disadvantage independent pharmacies and inflate drug costs.
FTC Chair Lina M. Khan underscored the issue, stating that these intermediaries are overcharging patients for cancer medications, generating additional revenue exceeding $1 billion.