A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards higher-priced medications and restricting their pharmacy options. This report follows a 32-month investigation and comes ahead of a hearing featuring executives from major PBM companies.
PBMs act as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—control about 80% of the nation’s prescription drugs.
The committee’s findings indicate that PBMs have prioritized lists of preferred medications that include higher-priced branded drugs over more affordable alternatives. For instance, emails from Cigna staff referenced in the report discourage the use of less expensive substitutes for Humira, an arthritis medication that was priced at $90,000 annually, despite the availability of a biosimilar option costing half that amount.
Moreover, Express Scripts has reportedly informed patients that filling a prescription at a local pharmacy would cost them more than obtaining a three-month supply from its affiliated mail-order service. This practice, according to the committee, restricts patients’ pharmacy choices.
A similar report released by the U.S. Federal Trade Commission (FTC) stated that the top six PBMs manage nearly 95% of all U.S. prescriptions, raising concerns about the concentration of power among these entities. The FTC expressed that the leading PBMs significantly impact Americans’ access to affordable medications and suggested that their integrated nature poses potential conflicts of interest that may disadvantage non-affiliated pharmacies and inflate drug prices.
FTC Chair Lina M. Khan highlighted that these findings indicate that these intermediaries are inflating costs for patients, especially for cancer medications, generating over $1 billion in extra revenue.