A recent report from the House Committee on Oversight and Accountability has raised concerns about pharmacy-benefit managers (PBMs) steering patients toward more expensive medications and restricting their pharmacy options. The findings follow a 32-month investigation by the committee prior to a hearing with executives from the largest PBMs in the country.
PBMs serve as intermediaries for health insurers regarding prescription drug plans, 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 approximately 80% of prescriptions filled.
The committee’s report highlights issues with PBMs creating preferred drug lists that favor higher-priced brand-name medications over cheaper alternatives. An instance cited in the report involved Cigna employees discouraging alternatives to Humira, a costly arthritis treatment priced at $90,000 annually, despite available biosimilars costing half that amount.
Additionally, the report notes 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 affiliated mail-order pharmacy, thus limiting patient choices.
Earlier this month, the Federal Trade Commission (FTC) issued a similar report, indicating that the top six PBMs now manage nearly 95% of all prescriptions in the U.S. The FTC expressed concern about the significant power these leading PBMs hold over Americans’ prescription drug access and affordability. The report suggests that this concentration can create conflicts of interest favoring their own affiliated businesses, potentially disadvantaging independent pharmacies and increasing drug costs.
FTC Chair Lina M. Khan remarked that these findings indicate PBMs are overcharging patients for cancer treatments, contributing more than $1 billion in additional revenue from these practices.