A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards costlier medications and restricting their pharmacy options. This findings come ahead of a committee hearing that will feature executives from the largest PBM companies.
PBMs serve as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical firms on behalf of health plans while also determining patients’ out-of-pocket costs. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage around 80% of prescriptions in the United States.
According to the report, PBMs have been prioritizing high-priced brand-name medications over more affordable alternatives. An example cited is from Cigna, where emails revealed discouragement towards using cheaper options for Humira, a costly treatment for arthritis and autoimmune disorders priced at $90,000 annually, despite the availability of a biosimilar priced at half that amount.
The investigation also found that Express Scripts informed patients that filling prescriptions at their local pharmacies would cost them more than obtaining a three-month supply through their mail-order service. This practice effectively limits patient options for pharmacies.
Earlier this month, the Federal Trade Commission published a similar report, noting that the six largest PBMs manage nearly 95% of all prescriptions in the country. This concentration of power raises concerns regarding patient access and affordability of medications. The FTC highlighted that the leading PBMs possess considerable influence over prescription drug access for Americans. Additionally, vertically integrated PBMs may prioritize their affiliated businesses, introducing conflicts of interest that could disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan emphasized that the findings indicated that these middlemen are significantly raising costs for patients, particularly for cancer medications, yielding over $1 billion in additional revenue.