A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward costlier medications while restricting their options for where to obtain these drugs.
The findings come after a 32-month investigation by the committee, which precedes a hearing featuring executives from the major PBMs. These managers serve as third-party administrators for prescription drug plans on behalf of health insurers, negotiating drug prices with pharmaceutical companies and determining patient out-of-pocket expenses.
The report indicates that the three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of the nation’s prescriptions.
According to the report, PBMs have established preferred drug lists that often include higher-priced brand-name medications instead of more affordable alternatives. For instance, it mentions communications from Cigna staff that advised against using lower-cost substitutes for Humira, an arthritis treatment with an annual cost of $90,000, despite the availability of a biosimilar at half that price.
Moreover, Express Scripts informed patients that they would incur higher costs by filling prescriptions at local pharmacies rather than ordering a three-month supply from its mail-order service, effectively limiting patient choice in pharmacy selection.
In a related issue, the U.S. Federal Trade Commission (FTC) recently released an interim report highlighting that increasing vertical integration has led the six largest PBMs to manage nearly 95% of prescriptions in the country. The FTC expressed concerns about the significant influence PBMs hold over Americans’ access to affordable medications, noting conflicts of interest that may arise from PBMs favoring their own associated businesses, potentially marginalizing independent pharmacies, and driving up prescription drug prices.
FTC Chair Lina M. Khan pointed out that these middlemen are reportedly overcharging patients for cancer medications, resulting in over $1 billion in additional revenue for the PBMs.