A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients towards pricier medications while restricting their options for obtaining these drugs. The findings stem from a 32-month investigation by the committee and precede a hearing featuring executives from major PBMs.
PBMs act as intermediaries that manage prescription drug plans for health insurers, negotiating drug prices and determining patients’ out-of-pocket expenses. The top three PBMs in the U.S. — Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark — control about 80% of the prescriptions in the country.
According to the committee’s findings, PBMs maintain preferred drug lists that favor more expensive branded medications over cheaper alternatives. The report highlights communications from Cigna staff that discouraged patients from opting for less costly substitutes for Humira, a medication for arthritis and autoimmune conditions priced at $90,000 annually, despite the availability of a biosimilar for roughly half that cost.
The investigation also uncovered that Express Scripts informs patients they would incur higher costs by filling prescriptions at local pharmacies compared to ordering a three-month supply from its own mail-order service, thus limiting patient choices regarding pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that increased consolidation among the top PBMs has enabled them to oversee nearly 95% of all U.S. prescriptions. The FTC warned that this scenario grants significant power to these PBMs over the affordability and accessibility of prescription drugs for Americans, potentially creating conflicts of interest that may hinder unaffiliated pharmacies and raise drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen are likely overcharging patients for cancer medications, contributing additional revenue exceeding $1 billion.