A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications and restricting their pharmacy options. This came to light following a 32-month investigation by the committee, which coincided with a hearing featuring executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating prices with drug manufacturers and determining the out-of-pocket expenses patients face. The three most significant PBMs in the U.S.—Express Scripts, OptumRx (owned by UnitedHealth Group), and Caremark (part of CVS Health)—control about 80% of all prescriptions.
The committee’s findings suggest these PBMs are favoring higher-priced brand-name drugs over less expensive alternatives. For instance, the report includes communications from Cigna employees discouraging the use of lower-cost options to Humira, an arthritis medication that costs $90,000 a year, even though a biosimilar alternative was available for half that price.
Additionally, it was noted that Express Scripts informed patients they’d pay more for prescriptions filled at their local pharmacies than if they obtained a three-month supply through its affiliated mail-order service, thus limiting patients’ choices regarding where they fill their prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, highlighting that the six largest PBMs manage nearly 95% of all filled prescriptions in the U.S. The FTC expressed concern over the substantial influence these major PBMs have on the accessibility and affordability of prescription drugs for Americans. The FTC report warned that vertically integrated PBMs might prioritize their own businesses, leading to conflicts of interest that can disadvantage independent pharmacies and inflate drug costs. According to FTC Chair Lina M. Khan, these middlemen are reportedly overcharging patients for cancer medications, generating over $1 billion in extra revenue.