A recent report from the House Committee on Oversight and Accountability alleges that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting their access to various pharmacies. The findings, which were made public prior to a hearing that included top executives from major PBMs, emerged after a comprehensive 32-month investigation by the committee.
PBMs serve as intermediaries that manage prescription drug plans for health insurers, negotiating prices with pharmaceutical companies on behalf of health plans and establishing patient out-of-pocket costs. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of all prescriptions filled in the country.
According to the report, these managers maintain lists of preferred medications that disproportionately feature higher-priced brand-name options instead of more affordable alternatives. An example highlighted in the report involves communications from Cigna employees that advised against the use of cheaper substitutes for Humira, a drug treating arthritis and other autoimmune disorders, which had an annual cost of $90,000, while a biosimilar was available at half that price.
Additionally, the committee discovered that Express Scripts informed patients that filling prescriptions at local pharmacies would be more expensive than obtaining a three-month supply from its affiliated mail-order service, thereby limiting patient pharmacy choices.
The U.S. Federal Trade Commission issued a similar report earlier this month, noting that growing vertical integration among PBMs has led the six largest to manage nearly 95% of prescriptions filled nationwide. The FTC expressed concern that leading PBMs now exert considerable influence over Americans’ access to and affordability of prescription medications. Furthermore, the report highlighted potential conflicts of interest, as vertically integrated PBMs may prioritize their own affiliated services, disadvantaging other pharmacies and driving up drug costs. FTC Chair Lina M. Khan indicated that these findings reveal how middlemen are overcharging patients for cancer treatments, contributing to over $1 billion in excess revenue.