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 pharmacy options. This report emerged from a 32-month investigation prior to a hearing involving executives from the three largest PBMs in the country.
PBMs serve as intermediary administrators for prescription drug plans on behalf of health insurers, negotiating costs with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three biggest players in this sector—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (affiliated with CVS Health)—are responsible for about 80% of prescriptions filled in the U.S.
The committee’s findings indicate that PBMs have developed lists of preferred medications that favor pricier brand names over less expensive alternatives. For instance, the report highlighted emails from Cigna employees advising against using cheaper substitutes for Humira, an arthritis treatment costing around $90,000 annually, despite the availability of a biosimilar priced at half that amount.
Additionally, the investigation uncovered practices where Express Scripts informed patients they would incur higher costs by using local pharmacies as opposed to obtaining a three-month supply through its mail-order service, thereby limiting patient choices.
An earlier report from the U.S. Federal Trade Commission (FTC) echoed these concerns, revealing that the six largest PBMs control nearly 95% of all prescriptions filled in the country. The FTC expressed alarm over the substantial influence these leading PBMs have over Americans’ access to affordable medications, noting that their vertical integration generates conflicts of interest and can disadvantage independent pharmacies, leading to elevated drug costs.
FTC Chair Lina M. Khan emphasized that the findings demonstrate how middlemen in the prescription drug market are significantly overcharging patients for cancer medications, with profits exceeding $1 billion.