A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are pushing patients towards more costly medications while restricting their choices regarding where to obtain them. This report stems from a 32-month investigation and precedes a forthcoming hearing involving executives from the country’s largest PBMs.
PBMs act as third-party administrators of prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs in the U.S. — Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark — control around 80% of the nation’s prescriptions.
The committee’s findings indicate that PBMs have prioritized lists of preferred medications featuring higher-priced brand-name drugs over more affordable alternatives. For instance, emails from Cigna staff discouraged patients from opting for cheaper alternatives to Humira, a treatment for arthritis that was priced at $90,000 annually, despite the availability of a biosimilar at half that cost.
Additionally, Express Scripts reportedly informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to ordering a three-month supply from its affiliated mail-order service. This practice has been criticized for restricting patients’ pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that increasing consolidation has allowed the six largest PBMs to manage nearly 95% of all prescriptions in the country. The FTC expressed concern, noting that leading PBMs wield considerable influence over Americans’ access to affordable prescription medications. The report highlights a conflict of interest where PBMs may prefer their own affiliated services, disadvantaging independent pharmacies and inflating prescription drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue from these practices.