A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are guiding patients toward more expensive medications while limiting their pharmacy options. This report follows a 32-month investigation ahead of a hearing involving executives from the nation’s major PBMs.
PBMs serve as third-party administrators for prescription drug plans, negotiating prices with pharmaceutical companies and determining patient out-of-pocket costs. The three largest PBMs in the U.S., Express Scripts, OptumRx, and Caremark, manage about 80% of prescription medications.
The committee’s findings indicate that PBMs have developed lists of preferred medications, favoring high-priced brand-name drugs over cheaper alternatives. An example highlighted in the report involves Cigna, which discouraged the use of a more affordable alternative to Humira, a costly treatment for arthritis and other autoimmune diseases.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from their mail-order service. This practice reportedly restricts patient choice in selecting pharmacies.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that the top six PBMs manage nearly 95% of all prescriptions in the nation. The FTC’s findings are concerning, indicating that leading PBMs now possess considerable influence over Americans’ access to and affordability of prescription medications. The report suggests that vertically integrated PBMs may prioritize their affiliated businesses, leading to potential conflicts of interest and higher prescription costs.
FTC Chair Lina M. Khan pointed out that these middlemen may be overcharging patients for cancer treatments, contributing to over $1 billion in additional revenue.