A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward costlier medications and limiting their access to a variety of pharmacies. This investigation, which lasted 32 months, was conducted prior to an upcoming hearing involving leaders from major PBMs.
PBMs serve as intermediaries managing prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (a CVS Health subsidiary)—oversee approximately 80% of prescriptions in the United States.
The report highlights that these PBMs often prefer higher-priced brand-name drugs over more affordable alternatives. An example cited in the report reveals internal communications from Cigna that discouraged the use of lower-cost options for Humira, a treatment for autoimmune conditions that cost $90,000 annually, even though a biosimilar was available for half that price.
Additionally, the committee found that Express Scripts informed patients they would incur higher costs if they chose to fill prescriptions at local pharmacies compared to obtaining a three-month supply from its own mail-order service. This practice has significantly limited patient choices for pharmacy locations.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that the top six PBMs control nearly 95% of all prescriptions filled in the U.S. The FTC’s findings are concerning, indicating that dominant PBMs hold considerable power over Americans’ access to affordable medications. They create a scenario where these integrated PBMs may favor their own businesses, leading to conflicts of interest that disadvantage independent pharmacies and raise prescription drug prices.
FTC Chair Lina M. Khan commented that these findings demonstrate how these middlemen have been overcharging patients for cancer treatments, resulting in over $1 billion in additional revenue for them.