A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward costlier medications while also restricting pharmacy options. This represents the first lawsuit McDonald’s faces following the E. coli outbreak linked to its Quarter Pounder.
The report, which followed a lengthy 32-month investigation, highlights concerns regarding PBMs, third-party administrators responsible for managing prescription drug plans for health insurers. These managers negotiate prices with pharmaceutical companies and determine out-of-pocket expenses for patients.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—account for nearly 80% of all prescriptions filled in the country. The report indicates that these PBMs have created preferred drug lists that favor higher-priced branded medications over more affordable alternatives.
One notable example cited in the report includes communications from Cigna discouraging the use of less expensive alternatives to Humira, an arthritis treatment that previously cost around $90,000 annually, despite the availability of a similar medication for half that price.
Additionally, the committee discovered that Express Scripts informed patients they would incur greater costs by filling prescriptions at local pharmacies instead of using their affiliated mail-order service, thereby restricting patient choices regarding pharmacy access.
A Federal Trade Commission (FTC) report released earlier this month echoes similar concerns. The FTC indicated that the consolidation in the industry has allowed the six largest PBMs to control nearly 95% of prescriptions in the U.S. The findings suggest that these dominant PBMs significantly influence patients’ ability to access affordable medications, raising potential conflicts of interest and driving up drug costs through their control over affiliated businesses.
According to FTC Chair Lina M. Khan, these middlemen exploit their position, leading to overcharging patients for critical medications like cancer drugs, resulting in excess revenues exceeding $1 billion.