A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications while restricting their pharmacy options. This finding comes after a 32-month investigation and precedes a hearing with leaders from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating drug prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs in the U.S. — Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark — control about 80% of the nation’s prescriptions.
The committee’s report indicates that these PBMs maintain lists of preferred medications, often favoring more expensive brand-name drugs over lower-cost alternatives. An example highlighted in the report is Cigna, which reportedly discouraged the use of cheaper alternatives to Humira, an arthritis medication priced at $90,000 annually, even though a biosimilar was available for roughly half that cost.
Furthermore, the report states that Express Scripts informed patients that filling prescriptions at local pharmacies could result in higher costs compared to obtaining a three-month supply through their affiliated mail-order service. This practice effectively limits patients’ choices in selecting pharmacies.
In a related report, the U.S. Federal Trade Commission noted that increased consolidation has allowed the six largest PBMs to manage nearly 95% of prescriptions in the U.S. The FTC expressed concern about the significant influence these PBMs have on patients’ access and affordability of medication, suggesting that their operations may lead to conflicts of interest that can drive up prescription drug costs.
FTC Chair Lina M. Khan highlighted that these middlemen are potentially overcharging patients for cancer medications, resulting in over $1 billion in additional revenue.