A recent report from the House Committee on Oversight and Accountability indicates that pharmacy-benefit managers (PBMs) are guiding patients toward more expensive medications and restricting their pharmacy choices. This finding comes ahead of a committee hearing involving executives from the largest PBMs in the United States, following an extensive 32-month investigation.
PBMs act as intermediaries for health insurers, negotiating prescription drug prices with pharmaceutical companies and establishing out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control approximately 80% of U.S. prescription drugs.
The committee’s report highlights that PBMs are developing preferred drug lists that favor higher-priced brand medications over less expensive options. For instance, emails from Cigna reportedly discouraged the use of more affordable alternatives to Humira, a medication for arthritis and other autoimmune disorders, which had a cost of $90,000 annually, while a biosimilar was available for half that price.
Additionally, Express Scripts informed patients that they would incur higher costs by filling prescriptions at local pharmacies rather than opting for a three-month supply through its affiliated mail-order service, thus limiting patient choice.
Earlier this month, the U.S. Federal Trade Commission released a similar report indicating that the six largest PBMs manage nearly 95% of prescriptions filled in the country. The FTC raised concerns about the significant influence these PBMs have over patients’ access to and affordability of medications, suggesting that their operations create conflicts of interest that could raise drug costs.
FTC Chair Lina M. Khan noted that these intermediaries are reportedly “overcharging patients for cancer drugs,” resulting in excess revenue of over $1 billion for themselves.