A recent report by the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting their options for where to obtain them. This investigation, which lasted 32 months, was released just before a hearing involving executives from the nation’s major PBMs.
PBMs act as intermediaries for prescription drug plans, working with health insurers and pharmaceutical companies to determine drug prices and patient out-of-pocket expenses. The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of the nation’s prescriptions.
The report highlights that PBMs have established preferred drug lists that tend to favor higher-priced brand-name medications over more affordable alternatives. For instance, emails from Cigna staff were cited, which indicated discouragement against choosing lower-cost alternatives to Humira, a treatment for various autoimmune conditions, which had an annual cost of $90,000 at the time, when a biosimilar was available for half that amount.
Furthermore, the committee discovered that Express Scripts informed patients they would incur higher costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service. This practice significantly limits patients’ choices regarding their pharmacy options.
The U.S. Federal Trade Commission (FTC) released a similar report earlier this month, stating that increasing vertical integration among PBMs now enables the six largest to control nearly 95% of all prescriptions filled in the country. The FTC emphasized that this power poses serious concerns for patients’ access to affordable medications.
FTC Chair Lina M. Khan remarked that these findings suggest that PBMs are “overcharging patients for cancer drugs,” resulting in excess revenues exceeding $1 billion.