A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their pharmacy options. This investigation, which spanned 32 months, comes ahead of a hearing featuring executives from the country’s largest PBMs.
PBMs serve as intermediaries for prescription drug plans, negotiating with pharmaceutical companies on pricing while determining patients’ out-of-pocket costs. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—handle about 80% of prescriptions nationwide.
According to the report, PBMs have prioritized more expensive brand-name drugs over less costly alternatives in their preferred drug lists. An example highlighted includes Cigna’s internal communications, which advised against using cheaper alternatives to Humira, a costly arthritis treatment priced at $90,000 annually, despite the availability of a biosimilar at half the cost.
The committee’s findings also indicated that Express Scripts informed patients that they could save money by obtaining a three-month supply of medications from its mail-order pharmacy rather than their local pharmacies, thus limiting patient choice.
Moreover, a recent report from the U.S. Federal Trade Commission (FTC) echoed these concerns, noting that the six largest PBMs manage nearly 95% of all prescriptions in the United States due to growing vertical integration. The FTC highlighted the significant control these PBMs have over American patients’ access to affordable medications, suggesting that this creates conflicts of interest that can harm unaffiliated pharmacies and drive up prescription costs.
FTC Chair Lina M. Khan stated that these findings indicate PBMs are “overcharging patients for cancer drugs,” contributing to additional revenues exceeding $1 billion.