A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their options for obtaining them.
The report, which emerged following a 32-month investigation by the committee, is set to be discussed during an upcoming hearing involving executives from the country’s top PBMs. PBMs act as intermediaries that manage prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket expenses for patients.
The three largest PBMs in the United States—Express Scripts, OptumRx (a unit of UnitedHealth Group), and Caremark (owned by CVS Health)—account for around 80% of all prescriptions filled nationwide.
According to the committee’s findings, PBMs have been creating lists of preferred drugs that favor higher-priced brand-name medications over more affordable options. For instance, the report includes emails from Cigna staff that discouraged the use of lower-cost alternatives to Humira, a treatment for arthritis and autoimmune conditions, which was priced at $90,000 annually at that time, despite the availability of a biosimilar for approximately half that cost.
Furthermore, the committee reported that Express Scripts informed patients they would incur higher costs if they opted to fill their prescriptions at their local pharmacies compared to getting a three-month supply from its affiliated mail-order service, thereby limiting patient choice.
Earlier this month, the Federal Trade Commission (FTC) released a related report indicating that the six largest PBMs have come to control nearly 95% of all prescriptions filled in the U.S. This consolidation raises concerns about access and affordability of medications for Americans. The FTC highlighted that the dominant position of these PBMs allows them to create conflicts of interest, potentially prioritizing their affiliated businesses over independent pharmacies, which may result in higher medication costs.
FTC Chair Lina M. Khan noted that these findings reveal how these intermediaries may be overcharging patients for cancer drugs, leading to an additional revenue boost of over $1 billion for the PBMs.