A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their options for obtaining them. This report follows a 32-month investigation and is set to inform a hearing featuring executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans offered by health insurers. They negotiate prices with pharmaceutical companies and determine the out-of-pocket expenses patients face. The three largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—control around 80% of all prescriptions dispensed.
According to the committee’s findings, these managers favor lists of higher-priced brand-name drugs rather than cheaper alternatives. The report highlights communications from Cigna employees discouraging the use of more affordable options for Humira, a medication for arthritis, which at the time had an annual cost of $90,000, while a biosimilar version was available for half the price.
Furthermore, Express Scripts reportedly informed patients they would incur higher costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply through their mail-order service, which further restricted patient pharmacy choices.
A recent interim report from the U.S. Federal Trade Commission (FTC) echoed these concerns, stating that the top six PBMs dominate nearly 95% of prescriptions in the U.S. The FTC noted that this concentration grants significant power to PBMs over patients’ access to affordable medications, suggesting that vertically integrated PBMs might favor their associated businesses, leading to higher costs and disadvantages for independent pharmacies.
FTC Chair Lina M. Khan emphasized that these middlemen are overcharging patients for cancer treatments, generating more than $1 billion in additional revenue from such practices.