A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications while restricting their pharmacy options. This finding follows a 32-month investigation preceding a hearing featuring leaders from the country’s largest PBMs.
PBMs serve as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket costs. Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark dominate the market, overseeing approximately 80% of U.S. prescriptions.
The committee’s report indicates that PBMs are promoting lists of preferred medications that favor higher-priced brand-name drugs over less expensive alternatives. For instance, it highlights internal communications at Cigna that discouraged the use of cheaper substitutes for Humira, an arthritis treatment costing $90,000 annually, despite a biosimilar option available for half that price.
Additionally, the investigation revealed that Express Scripts informed patients they would incur higher costs by using local pharmacies compared to purchasing a three-month supply through its affiliated mail-order service, thus restricting patients’ pharmacy choices.
The U.S. Federal Trade Commission (FTC) released a similar report earlier this month, noting that the six largest PBMs control nearly 95% of all prescriptions filled in the country. The FTC expressed concern over the considerable influence these PBMs have on Americans’ access to affordable medications, suggesting that their integration with pharmacies may lead to conflicts of interest and elevated drug costs.
FTC Chair Lina M. Khan remarked that the findings demonstrate how these intermediaries are charging patients excessively for cancer drugs, resulting in over $1 billion in additional revenue for them.