A recent report from the House Committee on Oversight and Accountability highlights concerns regarding pharmacy-benefit managers (PBMs) directing patients toward more expensive medications and restricting their pharmacy choices. The findings were published following a comprehensive 32-month investigation prior to a hearing that included executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket costs for patients. The three largest PBMs in the U.S.—Express Scripts, OptumRx (UnitedHealth Group), and Caremark (CVS Health)—control about 80% of the nation’s prescriptions.
The committee’s report indicates that PBMs have established preferred drug lists that favor higher-cost brand-name medications over more affordable options. For instance, it references internal communications from Cigna discouraging the use of cheaper alternatives to Humira, which at the time had an annual cost of $90,000, despite the availability of a biosimilar at half that price.
Additionally, the report notes instances where Express Scripts informed patients that filling a prescription at a local pharmacy would be more expensive than obtaining a three-month supply from its affiliated mail-order pharmacy, effectively limiting patient choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report, indicating that the growing concentration and vertical integration within the industry have allowed the six largest PBMs to oversee nearly 95% of all prescriptions distributed in the U.S. The FTC’s interim report warns that leading PBMs wield considerable power over public access to affordable medications, creating potential conflicts of interest that could harm independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan pointed out that these intermediaries are allegedly “overcharging patients for cancer drugs,” contributing to an excess revenue of over $1 billion.