A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications and restricting their pharmacy options.
The findings, which come ahead of a committee hearing involving executives from major PBMs, highlight a 32-month investigation conducted by the committee. PBMs act as intermediaries for health insurers, overseeing prescription drug plans and negotiating prices with pharmaceutical companies. They also determine out-of-pocket expenses for patients.
The report indicates that the three largest PBMs in the U.S. — Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark — control around 80% of prescriptions in the country.
According to the report, PBMs have established preferred drug lists that favor higher-priced brand-name drugs over more affordable alternatives. One example involves Cigna staff discouraging the use of lower-cost alternatives to Humira, an arthritis treatment that cost $90,000 annually, despite the availability of a biosimilar priced at around half that amount.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs at local pharmacies compared to ordering a three-month supply from their mail-order pharmacy, thereby limiting patient choice in where to fill prescriptions.
A recent report from the U.S. Federal Trade Commission (FTC) echoed these concerns, stating that the top six PBMs manage almost 95% of all prescriptions filled in the United States. The FTC highlighted the significant influence these PBMs have over public access to and affordability of prescription drugs, noting that this environment creates conflicts of interest that can disadvantage independent pharmacies and inflate drug costs.
FTC Chair Lina M. Khan emphasized that the findings suggest patients are being overcharged for cancer medications, resulting in additional profits exceeding $1 billion for these middlemen.