According to a new report from the House Committee on Oversight and Accountability, pharmacy-benefit managers (PBMs) are pushing patients towards more expensive medications while restricting their access to alternative options. This findings follow a 32-month investigation by the committee, which will hold a hearing that includes executives from the nation’s largest PBM companies.
PBMs serve as intermediaries between health insurers and prescription drug plans, negotiating prices with pharmaceutical firms and determining patient out-of-pocket costs. The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—account for around 80% of the country’s prescription medications.
The committee’s report indicates that PBMs have developed preferred drug lists that favor higher-priced brand-name drugs over less expensive alternatives. For instance, the report references emails from Cigna that suggested avoiding lower-cost options for Humira, which is used to treat arthritis and other autoimmune disorders, despite the presence of a biosimilar available at half the price.
Additionally, Express Scripts was reported to have informed patients that they would incur higher costs if they filled prescriptions at local pharmacies compared to ordering a three-month supply through its own mail-order services, thereby limiting patient choice.
A similar report was released by the U.S. Federal Trade Commission (FTC) earlier in the month, indicating that increased concentration within the PBM sector has enabled the six largest PBMs to manage nearly 95% of all prescriptions in the U.S. The FTC expressed concern that these PBMs hold substantial power over prescription drug accessibility and affordability, leading to potential conflicts of interest as they may prefer their own affiliated businesses.
FTC Chair Lina M. Khan highlighted that these findings suggest that PBMs are overcharging patients for cancer treatments and extracting over $1 billion in additional revenues.