A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards pricier medications while limiting their pharmacy options. This report follows a 32-month investigation into PBMs, which are third-party administrators overseeing prescription drug plans for health insurers. These managers negotiate prices with pharmaceutical companies and determine out-of-pocket costs for patients.
The three largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—control about 80% of prescription medications in the country. The committee’s findings indicate that PBMs are promoting lists of preferred drugs that feature higher-cost brand-name options instead of less expensive alternatives.
For instance, the report references correspondence from Cigna’s staff that discouraged using more affordable options to Humira, a treatment for arthritis that can cost around $90,000 annually, despite the availability of biosimilars at half the cost.
Additionally, Express Scripts reportedly informed patients that obtaining prescriptions from their local pharmacies would be more expensive than ordering a three-month supply via their affiliated mail-order service, thereby restricting patient choices regarding pharmacy options.
Earlier this month, the Federal Trade Commission (FTC) published a similar report indicating that the six largest PBMs manage nearly 95% of all prescriptions in the U.S., highlighting concerns about their increasing power over patients’ access to affordable drugs. The FTC expressed that the current landscape fosters conflicts of interest as vertically integrated PBMs may prefer their own affiliated companies, potentially raising drug costs for consumers.
FTC Chair Lina M. Khan emphasized that these middlemen are allegedly overcharging patients for cancer medications, generating excess revenue exceeding $1 billion.