Pharmacy-benefit managers (PBMs) are reportedly directing patients towards higher-cost medications while restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability.
This report, which follows a 32-month investigation, was released ahead of a hearing that will feature executives from the country’s leading PBMs.
PBMs act as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket costs for patients. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of prescriptions in the United States.
The committee’s findings reveal that PBMs are promoting lists of preferred drugs that prioritize higher-priced brand-name medications over more cost-effective alternatives. For instance, emails from Cigna staff advised against choosing less expensive substitutes for Humira, an arthritis and autoimmune disorder treatment priced at $90,000 annually, despite the existence of a biosimilar available for half that amount.
Additionally, Express Scripts informed patients they could incur higher costs by using their local pharmacy than by opting for a three-month supply through its mail-order service, thereby limiting patient pharmacy choices.
A concurrent report from the U.S. Federal Trade Commission highlighted similar concerns, noting that the consolidation of power among the six largest PBMs allows them to control nearly 95% of all prescriptions filled in the nation.
The FTC expressed alarm over these developments, stating that major PBMs wield considerable influence over Americans’ access to affordable prescription medications. The agency noted that this situation fosters conflicts of interest, as vertically integrated PBMs may favor their own affiliated businesses at the expense of independent pharmacies, potentially driving up drug prices.
According to FTC Chair Lina M. Khan, the evidence suggests that these intermediaries are “overcharging patients for cancer drugs,” resulting in over $1 billion in additional revenue for them.