A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards pricier medications while restricting their choice of pharmacies. This follows a comprehensive 32-month investigation which coincides with a planned hearing on PBMs featuring executives from the major firms in the industry.
PBMs act as intermediaries for health insurers, handling prescription drug plans by negotiating prices with pharmaceutical companies and determining out-of-pocket expenses for patients. The three largest PBMs in the U.S.—Express Scripts, OptumRx of UnitedHealth Group, and CVS Health’s Caremark—account for about 80% of all prescriptions in the country.
According to the report, these managers have been prioritizing lists of expensive brand-name medications over more affordable generic options. For instance, emails from Cigna employees revealed discouragement towards using cheaper alternatives for Humira, a medication for arthritis and autoimmune conditions that yearly costs around $90,000, despite the availability of a biosimilar at about half that price.
Furthermore, the committee noted that Express Scripts informed patients they would incur higher costs by using local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service. This practice limits patients’ pharmacy choices.
In a related report released earlier this month, the U.S. Federal Trade Commission highlighted that increased consolidation in the PBM sector has resulted in the largest six PBMs controlling nearly 95% of all prescriptions filled in the country. The FTC’s findings emphasize concerns over PBMs’ influence on access to affordable medications, suggesting that these entities potentially favor their own affiliated businesses, leading to higher drug costs and disadvantaged independent pharmacies.
FTC Chair Lina M. Khan underscored that these findings indicate that PBMs are overpricing cancer medications, generating over $1 billion in excess revenue at the expense of patients.