A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while simultaneously restricting their choice of pharmacies. This comes after a 32-month investigation leading up to a hearing involving executives from major PBM players in the industry.
PBMs act as middlemen for prescription drug plans under health insurers, negotiating prices with drug manufacturers and determining out-of-pocket costs for patients. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—are responsible for managing nearly 80% of prescriptions in the United States.
The committee identified that PBMs often maintain lists of preferred medications that promote higher-priced brand-name drugs over more affordable options. An example highlighted in the report includes communications from Cigna staff that advised against using lower-priced alternatives to Humira, a drug used to treat arthritis and other autoimmune conditions, which was priced at $90,000 per year, even though a biosimilar was available for around half that cost.
Additionally, the report indicated that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, effectively limiting pharmacy choices for patients.
Furthermore, a recent update from the U.S. Federal Trade Commission (FTC) echoed these findings, emphasizing that the six largest PBMs control nearly 95% of all prescriptions in the U.S. The FTC expressed concern over the significant influence these PBMs have on drug accessibility and affordability for Americans. It warned that this consolidation leads to potential conflicts of interest that could disadvantage independent pharmacies and raise prescription prices.
FTC Chair Lina M. Khan criticized the role of these middlemen, claiming they are “overcharging patients for cancer drugs” and generating excess profits exceeding $1 billion.