A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications and restricting their access to pharmacies.
This report comes after a 32-month investigation by the committee and precedes a hearing featuring executives from the largest PBM firms in the country. PBMs serve as intermediaries for prescription drug plans managed by health insurers and negotiate pricing with pharmaceutical companies, determining the costs patients face out-of-pocket.
The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—control around 80% of prescriptions filled in the U.S. The findings indicate that these managers favor higher-priced brand-name drugs over less expensive alternatives in their lists of preferred medications.
One example discussed in the report involves Cigna discouraging the use of a cheaper alternative to Humira, a treatment for arthritis that costs around $90,000 annually, while a biosimilar version was available for half that amount. Furthermore, Express Scripts informed patients that filling their prescriptions at local pharmacies would be costlier than obtaining a three-month supply through its affiliated mail-order service, thus limiting patient choice in pharmacy selection.
In a related report, the U.S. Federal Trade Commission highlighted that increased consolidation within the industry enables the six largest PBMs to manage about 95% of prescriptions filled across the nation. The FTC’s findings raise concerns regarding the significant influence PBMs have over Americans’ access to affordable medications.
FTC Chair Lina M. Khan stated that these middlemen are “overcharging patients for cancer drugs,” generating additional revenues exceeding $1 billion.