A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their pharmacy choices. This report follows a 32-month investigation and comes ahead of a hearing featuring executives from the largest PBMs in the country.
PBMs act as intermediaries managing prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and establishing patient out-of-pocket costs. The three largest PBMs—Express Scripts, OptumRx, and Caremark—handle about 80% of U.S. prescriptions.
The committee’s findings indicate that PBMs often compile lists of preferred medications that favor higher-priced brand-name drugs over more affordable options. For instance, emails from Cigna were revealed, discouraging the use of cheaper alternatives to Humira, a treatment for arthritis costing around $90,000 annually, despite the availability of biosimilars at half that price.
Additionally, Express Scripts reportedly informed patients that they would incur higher costs by obtaining prescriptions from local pharmacies compared to ordering a three-month supply through its affiliated mail-order service, which restricts patient pharmacy choices.
A similar report from the U.S. Federal Trade Commission highlighted the growing dominance of the six largest PBMs, which manage nearly 95% of all U.S. prescriptions. The FTC expressed concern over the substantial influence PBMs have on Americans’ access to affordable medications and raised alarms about potential conflicts of interest, as vertically integrated PBMs may prioritize their affiliated businesses.
FTC Chair Lina M. Khan remarked that the findings reveal how these intermediaries may be overcharging patients for cancer drugs, resulting in over $1 billion in additional revenue for them.