A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications and restricting their pharmacy choices. The findings emerged from a 32-month investigation preceding a committee hearing involving executives from the country’s largest PBMs.
PBMs serve as intermediaries for health insurers in managing prescription drug plans, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three dominant PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—control about 80% of all U.S. prescriptions.
The committee’s investigation indicated that PBMs often compile lists of preferred medications that showcase higher-priced brand-name drugs rather than cheaper options. For instance, a Cigna email highlighted discouragement regarding less expensive alternatives for Humira, a medication for arthritis and autoimmune conditions that had a price tag of $90,000 annually, despite the availability of at least one biosimilar at half that cost.
Additionally, Express Scripts reportedly informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to utilizing its mail-order service. This practice restricts patients’ choices regarding their pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that the increasing consolidation among PBMs has allowed the six largest firms to manage nearly 95% of prescriptions filled in the United States. The FTC’s findings raise significant concerns about the influence PBMs wield over patient access and affordability regarding prescription medications. The agency highlighted that these vertically integrated PBMs may generate conflicts of interest which can disadvantage independent pharmacies and drive up costs for patients.
FTC Chair Lina M. Khan noted that the results indicate that these intermediaries are overcharging patients for cancer medications, generating over $1 billion in additional revenue.