A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while limiting their pharmacy options. This report, which stemmed from a 32-month investigation, comes ahead of a 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 patients’ out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (part of CVS Health)—together manage around 80% of the country’s prescriptions.
According to the committee’s findings, these PBMs favor more expensive branded medications over cheaper alternatives in their preferred drug lists. The report highlights internal communications from Cigna that discouraged utilizing more affordable substitutes for Humira, a treatment for arthritis, which cost approximately $90,000 annually, even though a biosimilar existed at half the price.
Furthermore, the investigation found that Express Scripts informed patients they would pay more at local pharmacies than if they opted for a three-month supply through its affiliated mail-order service, thereby restricting patient choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report, noting that the top six PBMs manage nearly 95% of all prescriptions in the U.S. The FTC expressed concern over the significant power these organizations wield over Americans’ access to affordable medications, stating that vertically integrated PBMs might prioritize their own businesses, leading to conflicts of interest and increased costs for prescription drugs.
FTC Chair Lina M. Khan indicated that these findings suggest that these intermediaries are overcharging patients for essential medications, particularly for cancer treatments, generating over $1 billion in extra revenue.