A recent report from the House Committee on Oversight and Accountability indicates that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications and restricting their access to pharmacies. This findings come after a 32-month investigation preceding a hearing involving executives from the largest PBM companies in the country.
PBMs, which serve as third-party overseers of prescription drug plans for health insurance providers, negotiate with pharmaceutical manufacturers about drug prices and determine patients’ out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control approximately 80% of prescriptions in the country.
The committee’s report highlights concerns that PBMs are promoting lists of preferred medications that prioritize higher-priced brand-name drugs over more affordable alternatives. For instance, emails from Cigna were referenced, discouraging the use of less expensive substitutes for Humira, a medication for arthritis and autoimmune conditions with a yearly cost of $90,000, despite the presence of a biosimilar available for half the price.
Furthermore, the committee discovered that Express Scripts informed patients they would face higher costs by using local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service. This tactic limits patients’ pharmacy options.
In a similar vein, the U.S. Federal Trade Commission (FTC) released a report earlier this month stating that “increasing vertical integration and concentration” among PBMs has allowed the six largest managers to handle nearly 95 percent of all U.S. prescriptions.
These alarming findings indicate that leading PBMs hold significant power over the accessibility and affordability of prescription medications for Americans. The FTC also expressed concerns that vertically integrated PBMs might favor their own associated businesses, which could harm independent pharmacies and escalate drug costs. FTC Chair Lina M. Khan remarked that these middlemen are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.