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 access to alternative options. The investigation, spanning 32 months, precedes a hearing involving executives from the largest PBMs in the country.
PBMs are responsible for administrating prescription drug plans for health insurers, negotiating costs with drug manufacturers, and determining patients’ out-of-pocket expenses. The three largest PBMs in the United States—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—control about 80% of the nation’s prescriptions.
According to the report, PBMs create preferred drug lists that often favor pricey brand-name medications over more affordable alternatives. An example noted in the report highlights Cigna’s internal communications, which discouraged the use of lower-cost substitutes for Humira, a drug used for arthritis and other autoimmune conditions, costing approximately $90,000 annually, despite the availability of biosimilars at half the price.
Furthermore, it was found that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from their affiliated mail-order service, thereby limiting patient choices regarding pharmacy use.
This report aligns with findings from the U.S. Federal Trade Commission (FTC), which earlier this month highlighted how increased vertical integration has allowed the six largest PBMs to dominate nearly 95% of all prescriptions in the U.S. The FTC warned that these developments give significant influence to leading PBMs over Americans’ access to affordable medications, and the system creates conflicts of interest that could disadvantage independent pharmacies while driving up drug costs.
FTC Chair Lina M. Khan emphasized that the findings indicate these intermediaries are overcharging patients for cancer medications, resulting in an excess revenue of over $1 billion for the PBMs.