A recent report from the House Committee on Oversight and Accountability has highlighted that pharmacy-benefit managers (PBMs) are directing patients towards higher-priced medications while restricting their choices of pharmacies. This report is based on a 32-month investigation and precedes an upcoming hearing on PBMs featuring executives from the largest companies in the sector.
PBMs act as intermediaries for prescription drug plans managed by health insurers. They negotiate pricing with drug manufacturers and establish out-of-pocket expenses for patients. The three leading PBMs in the U.S., Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health, manage around 80% of the country’s prescriptions.
The committee’s findings indicate that these PBMs have developed preferred drug lists that favor more expensive brand-name medications over less costly alternatives. One notable example mentioned in the report involves internal communications from Cigna that discouraged staff from recommending lower-priced options for Humira, a medication for arthritis and autoimmune disorders, which had an annual cost of $90,000, despite the availability of a biosimilar at half that price.
Additionally, the report reveals that Express Scripts informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through its mail-order service. This practice has been criticized for limiting patient pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that increasing consolidation among PBMs has allowed the six largest firms to control about 95% of all prescriptions filled in the nation. The FTC expressed concerns that these developments grant significant power to PBMs over patients’ access to affordable medications, leading to potential conflicts of interest that could disadvantage independent pharmacies while driving up drug costs.
FTC Chair Lina M. Khan emphasized that the findings reveal how these intermediaries may be overcharging patients for cancer treatments, generating over $1 billion in additional revenue for them.