A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards pricier medications while restricting their pharmacy options. This follows a 32-month investigation by the committee and coincides with an upcoming hearing featuring executives from the largest PBMs.
PBMs serve as intermediaries for prescription drug plans managed by health insurers. They negotiate drug prices with pharmaceutical firms and determine the out-of-pocket expenses for patients. The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of the nation’s prescriptions.
The committee found that these managers frequently curate preferred drug lists that prioritize expensive brand-name medications over more affordable alternatives. The report highlights that staff members at Cigna discouraged using lower-cost options for Humira, an arthritis treatment that was priced at $90,000 annually, despite the availability of a similar biosimilar drug priced at half that amount.
The committee also noted that Express Scripts informed patients they would incur higher costs for obtaining prescriptions at local pharmacies compared to acquiring a three-month supply through their affiliated mail-order service. This practice limits patients’ choices regarding where to fill their prescriptions.
Additionally, the U.S. Federal Trade Commission (FTC) released a report earlier this month indicating that increased consolidation has allowed the six largest PBMs to oversee nearly 95% of all prescriptions filled in the country. The FTC expressed concern over how these leading PBMs wield significant influence over Americans’ access to affordable medications. Their findings suggest that vertically integrated PBMs may favor their own affiliates, leading to conflicts of interest that could increase drug costs and disadvantage independent pharmacies.
FTC Chair Lina M. Khan stated that the findings indicate PBMs are overcharging patients for cancer treatments, resulting in an additional $1 billion in revenue for these intermediaries.