A recent report by the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting their pharmacy options. This report comes after a 32-month investigation into the practices of the major PBMs, which will be addressed in an upcoming hearing featuring executives from the country’s leading management firms.
PBMs serve as intermediaries for health insurance prescription drug plans, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs, Express Scripts, OptumRx (a division of UnitedHealth Group), and CVS Health’s Caremark, control about 80% of prescriptions dispensed in the United States.
The committee’s findings indicate that these PBMs preferentially include higher-cost brand-name drugs in their formularies, often sidelining less expensive alternatives. For instance, the report mentions that Cigna staff discouraged opting for more affordable substitutes for Humira, a medication priced at $90,000 annually, when biosimilars costing around half that were available.
Additionally, the report highlighted that Express Scripts informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through their mail-order service, limiting patients’ pharmacy choices.
A similar report from the Federal Trade Commission (FTC) released earlier this month notes that the leading six PBMs now handle nearly 95% of prescriptions filled in the U.S. The FTC expressed concerns about the significant influence these PBMs hold over Americans’ access to and affordability of prescription drugs, citing potential conflicts of interest that could disadvantage independent pharmacies and inflate costs for patients. FTC Chair Lina M. Khan emphasized that these middlemen are effectively “overcharging patients for cancer drugs,” generating excessive revenue exceeding $1 billion.