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. Following a 32-month investigation, the findings were shared ahead of a hearing featuring executives from the leading PBMs.
PBMs act as intermediaries for prescription drug plans provided by health insurers, negotiating prices with pharmaceutical companies and determining the out-of-pocket expenses for consumers. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of prescriptions filled in the United States.
The report highlights that these managers have developed preferred drug lists featuring higher-priced brand-name drugs over more affordable alternatives. For instance, internal communications from Cigna discouraged the use of cheaper substitutes for Humira, an arthritis treatment priced at $90,000 annually, despite the availability of a biosimilar for half that amount.
The committee also noted that Express Scripts informed patients that they would incur higher costs at local pharmacies compared to the price for a three-month supply through its mail-order services, further restricting patient choice.
Complementing this investigation, the U.S. Federal Trade Commission released a report stating that the largest six PBMs now manage nearly 95% of all prescriptions filled in the country. The FTC’s findings raise concerns about the immense influence PBMs have over access to affordable medications, suggesting they favor their own affiliated businesses, which can lead to higher costs for consumers.
According to FTC Chair Lina M. Khan, these middlemen are reportedly overcharging patients for cancer treatments, earning more than $1 billion in additional revenue.