A recent report from the House Committee on Oversight and Accountability alleges that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications and restricting their options for obtaining prescriptions. This investigation, lasting 32 months, precedes a hearing that will feature executives from the largest PBMs in the country.
Pharmacy-benefit managers act as third-party administrators for health insurers’ prescription drug plans. They negotiate pricing with pharmaceutical companies and determine the out-of-pocket expenses for patients. The three largest PBMs in the United States—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—manage about 80% of all prescriptions written in the country.
According to the report, PBMs have generated lists of favored medications that prioritize higher-priced brand-name drugs over less expensive alternatives. For instance, emails from Cigna staff reportedly discouraged the use of lower-cost options for Humira, a medication for arthritis and other autoimmune disorders, which was priced at $90,000 annually, despite the availability of a biosimilar at half that cost.
The committee’s findings also indicate 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. This practice limits patients’ choices regarding where they can fill their prescriptions.
A recent report from the U.S. Federal Trade Commission echoed similar concerns, revealing that the six largest PBMs control nearly 95% of all prescriptions dispensed in the United States. The FTC warned that these leading PBMs wield significant influence over Americans’ access to affordable medications and may show favoritism towards their affiliated businesses, potentially leading to conflicts of interest that harm independent pharmacies and escalate drug costs.
FTC Chair Lina M. Khan highlighted that the findings indicate these middlemen are “overcharging patients for cancer drugs,” resulting in over $1 billion in additional revenue for them.