A new report from the House Committee on Oversight and Accountability indicates that pharmacy-benefit managers (PBMs) are guiding patients toward more costly medications and restricting their access to pharmacies. This report follows a lengthy 32-month investigation and precedes an upcoming hearing that will feature executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans for health insurance companies, negotiating pricing with pharmaceutical firms and determining the out-of-pocket expenses for consumers. The three largest PBMs in the United States—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—manage about 80% of the nation’s prescriptions.
The committee’s findings suggest that these PBMs are creating lists of preferred drugs favoring high-priced brand-name medications over more affordable options. For instance, the report references communications from Cigna staff encouraging the continued use of Humira, a drug for arthritis and other autoimmune disorders that costs around $90,000 per year, despite the availability of at least one biosimilar priced at half that amount.
Additionally, it was noted that Express Scripts informed patients they would incur higher costs by filling a prescription at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service. This practice was seen as a limitation on patient choice regarding pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission released a similar report indicating that growing vertical integration among major PBMs has resulted in these firms managing nearly 95% of all prescriptions filled across the country.
The implications of these findings are concerning, as the FTC highlighted the considerable influence PBMs have on Americans’ access to and affordability of prescription medications. It pointed out that vertically integrated PBMs might prioritize their own businesses, leading to potential conflicts of interest that disadvantage independent pharmacies and inflate drug costs. FTC Chair Lina M. Khan underscored that the evidence indicates these intermediaries are “overcharging patients for cancer drugs,” yielding them over $1 billion in additional revenue.