Pharmacy-benefit managers (PBMs) are reportedly directing patients toward costlier medications while restricting their choices in pharmacies, based on a recent report from the House Committee on Oversight and Accountability. This report, which comes after a 32-month investigation, precedes an upcoming hearing involving executives from the largest PBMs in the country.
PBMs serve as third-party administrators for prescription drug plans provided by health insurers, negotiating drug prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three biggest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of all prescriptions.
The committee’s findings indicate that PBMs have developed lists of preferred drugs that often feature higher-priced brand-name medications instead of more affordable alternatives. For instance, the report references emails from Cigna personnel that advised against using less expensive substitutes for Humira, a medication for arthritis and other autoimmune diseases, which was priced at $90,000 annually at the time, despite the availability of a biosimilar costing half that amount.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs filling prescriptions at local pharmacies compared to receiving a three-month supply from its own mail-order pharmacy, thereby restricting patients’ choices regarding where to fill their prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) published a corresponding report highlighting the dominance of the six largest PBMs, which manage nearly 95% of all prescriptions in the United States. The FTC’s findings raise concerns about the substantial influence PBMs wield over Americans’ access to affordable medications. The FTC indicated that this creates a situation where vertically integrated PBMs may favor their affiliated businesses, posing conflicts of interest that could disadvantage independent pharmacies and elevate medication costs.
FTC Chair Lina M. Khan noted that these middlemen are reportedly “overcharging patients for cancer drugs,” generating over $1 billion in added revenue.