A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are leading patients towards more expensive medications and restricting their pharmacy choices. This report, which followed a comprehensive 32-month investigation, was presented ahead of a hearing involving executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans on behalf of health insurers, negotiating costs with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs in the U.S. – Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark – control about 80% of all prescriptions filled.
The committee’s findings indicate that PBMs have crafted preferred drug lists that favor pricier brand-name medications over less expensive alternatives. For instance, emails from Cigna employees revealed discouragement toward using more affordable substitutes for Humira, a treatment for arthritis, despite the availability of a biosimilar at half the price.
Moreover, Express Scripts reportedly informed patients that they would incur greater costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service, effectively limiting patient choices.
This issue has echoed earlier concerns raised by the U.S. Federal Trade Commission (FTC), which noted that the top six PBMs control nearly 95% of all prescriptions in the United States. The FTC expressed alarm at the disproportionate power PBMs wield over the access and affordability of prescription medications, suggesting that their vertical integration creates conflicts of interest that may disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan highlighted that these practices have resulted in PBMs overcharging patients for cancer treatments, contributing an excess revenue exceeding $1 billion.