A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications and restricting their pharmacy options. This report, which follows a 32-month investigation, comes ahead of a committee hearing featuring executives from the largest PBM companies in the country.
PBMs act as intermediaries for prescription drug plans for health insurers, negotiating prices with pharmaceutical firms and determining out-of-pocket expenses for patients. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage around 80% of all prescriptions filled in the country.
The findings of the report reveal that PBMs often compile lists of preferred drugs that prioritize expensive brand-name medications over more affordable alternatives. For instance, internal communications from Cigna discouraged the use of lower-cost alternatives to Humira, which at one point cost $90,000 annually, despite the presence of a biosimilar priced at half that amount.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to receiving a three-month supply through its mail-order service, thereby limiting patient choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, highlighting that increased consolidation within the industry allows the six largest PBMs to control nearly 95% of all U.S. prescriptions. The FTC’s findings are concerning, indicating that major PBMs have gained substantial leverage over patients’ access to affordable medications and revealing potential conflicts of interest that may disadvantage independent pharmacies while boosting prescription drug prices.
FTC Chair Lina M. Khan noted that these findings illustrate how middlemen are allegedly overcharging patients for cancer drugs, generating over $1 billion in additional revenue.