A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are guiding patients toward more expensive medications while restricting their pharmacy options. This report follows a comprehensive 32-month investigation ahead of a hearing involving executives from the country’s largest PBMs.
PBMs, which are third-party administrators for prescription drug plans, negotiate prices between health insurers and pharmaceutical companies and set patient out-of-pocket costs. The three major PBMs—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—manage about 80% of prescriptions in the United States.
The report indicates that these managers often promote higher-priced brand-name drugs over cheaper alternatives. For instance, emails from Cigna revealed efforts to discourage the use of less expensive options for Humira, an arthritis treatment that costs $90,000 annually, despite the availability of biosimilars at half that price.
Furthermore, the investigation uncovered that Express Scripts informed patients they would pay significantly more at local pharmacies compared to getting a three-month prescription supply from its affiliated mail-order pharmacy, thus limiting patient choice.
The U.S. Federal Trade Commission (FTC) echoed similar concerns in a report released earlier this month, stating that heightened vertical integration among PBMs has resulted in the six largest ones managing nearly 95% of all prescriptions filled in the U.S. The FTC concluded that these leading PBMs now have considerable control over Americans’ access to affordable medications, with evidence showing that they may be favoring their own businesses, which can harm independent pharmacies and escalate drug costs.
The findings by FTC Chair Lina M. Khan highlighted a troubling reality, stating that patients are being overcharged for essential medications, including cancer drugs, generating excess revenue exceeding $1 billion for these middlemen.