A recent report from the House Committee on Oversight and Accountability accuses pharmacy-benefit managers (PBMs) of directing patients toward costlier medications and restricting pharmacy options. This investigation spanned 32 months and was conducted ahead of an upcoming hearing involving executives from the largest PBMs in the nation.
PBMs serve as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket expenses for patients. The three largest PBMs in the U.S., Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health), manage about 80% of the nation’s prescriptions.
The committee’s findings indicate that PBMs create preferred drug lists that favor higher-priced brand-name medications instead of more affordable alternatives. For instance, the report includes communications from Cigna staff that discouraged opting for less expensive substitutes for Humira, an arthritis treatment with an annual cost of $90,000, despite at least one available biosimilar being priced at half that amount.
Additionally, the committee revealed that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies than through its affiliated mail-order service, thereby restricting patients’ access to their preferred pharmacies.
The U.S. Federal Trade Commission (FTC) issued a similar report recently, stating that the largest six PBMs control approximately 95% of U.S. prescriptions. The FTC expressed concerns about the considerable authority these leading PBMs wield in terms of Americans’ access to affordable medications, highlighting conflicts of interest stemming from vertically integrated businesses favoring their own affiliates.
FTC Chair Lina M. Khan noted that these findings indicate that PBMs are charging patients excessively for cancer medications, generating additional revenue exceeding $1 billion.