A recent report from the House Committee on Oversight and Accountability has unveiled that pharmacy-benefit managers (PBMs) are directing patients toward higher-priced medications while restricting their choice of pharmacies. This findings come following a 32-month investigation and are set against the backdrop of an upcoming hearing involving executives from the nation’s leading PBMs.
PBMs, which are third-party administrators overseeing prescription drug plans for health insurers, negotiate prices with pharmaceutical companies on behalf of health plans and determine out-of-pocket costs for patients. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (a division of CVS Health)—collectively manage around 80% of prescriptions in the United States.
The committee’s investigation revealed that PBMs favor listing pricier brand-name drugs over more affordable alternatives. For instance, emails from Cigna indicated a discouragement of cheaper options for Humira, a costly treatment for arthritis and other autoimmune disorders, priced at $90,000 annually, when at least one biosimilar was available for half that amount.
Moreover, the committee reported that Express Scripts informed patients that they would likely incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service. This practice restricts patient choices regarding where to fill their prescriptions.
In a related report, the U.S. Federal Trade Commission (FTC) highlighted that increased consolidation has allowed the six largest PBMs to manage almost 95% of all prescriptions within the country. The FTC’s findings suggest that dominant PBMs hold significant influence over Americans’ access to and affordability of prescription drugs. The vertical integration of these companies has led to potential conflicts of interest, disadvantaging independent pharmacies and driving up costs for consumers.
FTC Chair Lina M. Khan emphasized the findings point to PBMs overcharging patients for essential medications, particularly for cancer treatments, resulting in additional profits exceeding $1 billion.