A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications while restricting their pharmacy options. The findings come ahead of a hearing that will feature executives from the country’s largest PBMs.
PBMs act as intermediaries for health insurers in managing prescription drug plans. They negotiate prices with pharmaceutical companies and establish patients’ out-of-pocket expenses. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of prescriptions in the U.S.
According to the report, PBMs maintain lists of preferred medications that favor higher-cost brand-name drugs over more affordable alternatives. For instance, Cigna employees reportedly discouraged the use of less expensive substitutes for Humira, a medication for arthritis and other autoimmune conditions, which at one point cost $90,000 annually, despite having a biosimilar option available for about half that price.
Additionally, Express Scripts informed patients that filling prescriptions at local pharmacies would likely result in higher costs compared to obtaining a three-month supply through their mail-order pharmacy. This practice effectively restricts patients’ choices regarding where they can fill their prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, highlighting that the six largest PBMs oversee nearly 95% of all prescriptions in the country. The FTC expressed concern over the significant control these entities have over U.S. citizens’ access to affordable medications. It suggested that vertically integrated PBMs may prioritize their own affiliated businesses, which could lead to conflicts of interest that disadvantage independent pharmacies and increase drug costs.
FTC Chair Lina M. Khan noted that these middlemen are reportedly “overcharging patients for cancer drugs,” generating more than $1 billion in additional revenue for themselves.