A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are guiding patients toward pricier medications while restricting their access to pharmacy options. This findings come after a 32-month investigation in advance of a hearing that included executives from the nation’s largest PBMs.
PBMs serve as intermediaries for prescription drug plans, negotiating with pharmaceutical companies about drug pricing for health plans. They also set the out-of-pocket expenses that patients face.
The three largest PBMs in the U.S. — Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark — account for roughly 80% of prescription management in the country.
The committee’s investigation found that PBMs maintain preferred drug lists that favor higher-priced brand-name medications over more affordable alternatives. For instance, emails from staff at Cigna discouraged the use of cheaper substitutes for Humira, a medication for arthritis and autoimmune conditions that costs around $90,000 annually, even though a biosimilar was available for half that expense.
Moreover, Express Scripts informed patients that they would incur higher costs if they filled prescriptions at local pharmacies than if opting for a three-month supply through their affiliated mail-order service. This practice restricts patients’ freedom to choose their pharmacy.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that major PBMs control nearly 95% of all prescriptions filled in the United States due to increasing vertical integration and market concentration.
The FTC report highlights significant concerns, stating that leading PBMs wield considerable influence over Americans’ access and affordability of prescription medications. It warns that this dynamic creates conflicts of interest, potentially favoring affiliated businesses and driving up prescription costs. The FTC Chair, Lina M. Khan, pointed out that these middlemen are “overcharging patients for cancer drugs,” contributing over $1 billion in additional revenue.