A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications and restricting their options for obtaining them. This findings come after a 32-month investigation ahead of a committee hearing with executives from the largest PBMs in the country.
PBMs act as intermediaries for health insurers in managing prescription drug plans. Their responsibilities include negotiating prices with pharmaceutical companies and determining out-of-pocket costs for patients. The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—collectively handle about 80% of all prescriptions in the United States.
The committee’s report notes that PBMs often favor higher-priced brand-name drugs over cheaper alternatives. For instance, emails from Cigna employees highlighted efforts to dissuade the use of less expensive alternatives to Humira, an arthritis treatment priced at $90,000 annually, while at least one biosimilar was available for half that cost.
Furthermore, Express Scripts reportedly informed patients that obtaining a three-month supply of medication through its own mail-order service would be less expensive than filling a prescription at a local pharmacy, which effectively limited patient choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that increased concentration and vertical integration have allowed the six largest PBMs to control nearly 95% of all U.S. prescriptions. The FTC expressed concern over the substantial power these PBMs hold over Americans’ access to affordable medications, addressing conflicts of interest that may arise from PBMs favoring their own affiliated businesses.
FTC Chair Lina M. Khan emphasized that the findings demonstrate how PBMs may be overcharging patients for cancer drugs, generating over $1 billion in additional revenue.