A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications and restricting their pharmacy options. This report is based on a 32-month investigation and precedes a hearing involving executives from the largest PBMs in the country.
PBMs serve as intermediaries for health insurers managing prescription drug plans. They negotiate drug prices with pharmaceutical companies and determine patient out-of-pocket expenses. The three largest PBMs in the U.S. — Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark — control nearly 80% of the nation’s prescriptions.
According to the committee’s findings, PBMs have developed preferred drug lists that prioritize higher-cost brand-name medications over more affordable alternatives. For instance, emails from Cigna staff discouraged the use of more economical options for Humira, an arthritis treatment costing around $90,000 annually, when a biosimilar was available for half that price.
Additionally, the committee discovered that Express Scripts informed patients they would pay more at their local pharmacies than if they obtained a three-month supply through its mail-order service, thereby restricting patients’ pharmacy choices.
A similar report from the U.S. Federal Trade Commission (FTC) indicated that increased vertical integration has allowed the six largest PBMs to manage nearly 95% of all prescriptions in the U.S. The FTC’s interim report highlights concerns that major PBMs exert considerable control over patients’ access to affordable medications, potentially disadvantaging independent pharmacies and escalating prescription drug costs.
FTC Chair Lina M. Khan expressed that these findings indicate that PBMs are potentially overcharging patients for essential treatments, particularly cancer drugs, resulting in additional revenue exceeding $1 billion for these intermediaries.