A recent report from the House Committee on Oversight and Accountability highlights concerns regarding pharmacy-benefit managers (PBMs), which are reportedly directing patients toward higher-priced medications while limiting their pharmacy options. This report comes after a comprehensive 32-month investigation and is set to precede a hearing involving executives from the country’s largest PBMs.
PBMs act as intermediaries for health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket drug costs. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of prescription medications in the country.
The committee’s findings suggest that PBMs have established lists prioritizing costlier brand-name drugs over less expensive alternatives. One instance noted involved Cigna staff advising against using more affordable substitutes for Humira, a treatment that cost $90,000 annually, despite the availability of a biosimilar for half that amount.
Additionally, the report indicated that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, further restricting patient choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report stating that increasing consolidation among PBMs enables the six largest managers to oversee almost 95% of all prescriptions filled nationwide. The FTC’s findings raise alarm over the power these PBMs wield, affecting access to and affordability of medications for Americans. It also highlighted potential conflicts of interest, with vertically integrated PBMs favoring their own affiliated services, potentially disadvantaging independent pharmacies and raising drug prices.
FTC Chair Lina M. Khan called attention to how these intermediaries are reportedly “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.