A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are guiding patients toward more expensive medications while restricting their access to lower-cost options.
The findings came to light after a comprehensive 32-month investigation by the committee, which preceded a hearing involving executives from the largest PBM companies in the nation. PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control roughly 80% of the prescriptions filled in the country. The committee’s report indicates that these managers often provide lists of preferred medications that favor higher-priced brand-name drugs over cheaper alternatives.
For instance, the report references internal communications from Cigna that advised against using less expensive substitutes for Humira, an arthritis treatment priced at around $90,000 annually, despite the existence of a biosimilar costing only half that amount.
Additionally, Express Scripts reportedly informed patients that they would incur higher costs if they filled prescriptions at their local pharmacies compared to ordering a three-month supply through its affiliated mail-order service. This practice restricts patients’ choices regarding where to obtain their medications.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, highlighting that the top six PBMs manage approximately 95% of all prescriptions in the U.S., resulting in troubling implications for access and affordability of medications. The FTC noted that leading PBMs wield significant influence over patients’ ability to obtain necessary prescriptions, creating conflicts of interest that could disadvantage independent pharmacies and elevate drug prices.
FTC Chair Lina M. Khan emphasized that these findings indicate that these intermediaries are overcharging patients for cancer treatments, generating excess revenues exceeding $1 billion.