A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while also restricting their pharmacy options. This report comes after a 32-month investigation and is set to be discussed in an upcoming hearing with executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket costs. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control nearly 80% of all prescription drugs dispensed in the United States.
The committee’s findings indicate that these PBMs have created lists favoring more costly brand-name drugs over cheaper alternatives. An example highlighted in the report involves internal communications from Cigna, which advised against using less expensive substitutes for Humira, a treatment for arthritis that costs around $90,000 annually, when a biosimilar was available at half that price.
Additionally, the investigation uncovered that Express Scripts informed patients they would incur higher costs by using local pharmacies compared to obtaining a three-month supply from its own mail-order service, thereby restricting patients’ choices.
Earlier this month, the U.S. Federal Trade Commission issued a similar report, noting that the concentration and vertical integration of the six largest PBMs allow them to control about 95% of all prescriptions in the U.S. The FTC’s report raised concerns regarding these PBMs’ significant influence over Americans’ access to affordable medications, alleging that their practices may disadvantage independent pharmacies and contribute to rising drug costs.
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.