A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are guiding patients toward more expensive medications and restricting their pharmacy options. This investigation, which spanned 32 months, precedes a hearing involving executives from the largest PBM companies in the U.S.
PBMs serve as third-party administrators for prescription drug plans offered by health insurers and play a crucial role in negotiating drug prices with pharmaceutical companies. They also determine out-of-pocket expenses for patients. Currently, the three leading PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—manage about 80% of prescriptions in the United States.
The committee’s findings indicate that PBMs have established preferred drug lists that favor higher-priced brand-name medications over more affordable alternatives. One example highlighted in the report involved emails from staff at Cigna that discouraged the use of cheaper alternatives to Humira, an arthritis treatment costing around $90,000 annually, despite the availability of a biosimilar option priced at half that.
Additionally, the report pointed out that Express Scripts informed patients that filling prescriptions at local pharmacies would cost them more than obtaining a three-month supply through its affiliated mail-order service. This practice has been criticized for limiting patient choice regarding where they can fill their prescriptions.
A similar report from the U.S. Federal Trade Commission (FTC) released earlier this month noted that increased vertical integration among PBMs has allowed the six largest managers to control nearly 95% of all prescriptions in the country. The FTC expressed concerns about the power PBMs wield over Americans’ access to affordable medications and warned of potential conflicts of interest as vertically integrated PBMs may favor their own services and raise prescription costs for consumers.
FTC Chair Lina M. Khan emphasized that these findings indicate that middlemen are significantly inflating prices for cancer medications, generating over $1 billion in additional revenue from patients.