A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their pharmacy options. This report, based on a 32-month investigation, was reviewed ahead of a hearing featuring executives from the country’s largest PBMs.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket costs. The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control approximately 80% of prescriptions filled.
The committee’s findings indicate that these PBMs have been promoting lists of preferred medications that include higher-priced brand names over more affordable alternatives. For instance, emails from Cigna’s staff discouraged the use of less expensive options for Humira, a treatment for arthritis and other autoimmune diseases, which cost $90,000 annually, despite the availability of biosimilars priced at half that amount.
Additionally, Express Scripts informed patients that filling prescriptions at their local pharmacies would result in higher costs compared to obtaining a three-month supply from their affiliated mail-order service. This practice restricts patients’ pharmacy choices.
A similar report released earlier this month by the U.S. Federal Trade Commission (FTC) stated that the largest PBMs manage nearly 95% of all prescriptions in the U.S. The FTC’s interim report highlighted concerns about the significant power these PBMs wield over Americans’ access to and affordability of prescription drugs. It also pointed out that vertically integrated PBMs have the potential to favor their own businesses, creating conflicts of interest that could disadvantage independent pharmacies and raise drug prices.
FTC Chair Lina M. Khan remarked that these findings indicate the middlemen are “overcharging patients for cancer drugs,” generating additional revenue exceeding $1 billion.