A recent report from the House Committee on Oversight and Accountability highlights that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications and restricting their access to various pharmacies. This study, which spans over 32 months, precedes a hearing that will include executives from the largest PBMs in the country.
PBMs serve as intermediaries that manage prescription drug plans for health insurers. They negotiate prices with pharmaceutical companies and determine the out-of-pocket costs that patients face. The three dominant players in this market—Express Scripts, OptumRx, and Caremark—control about 80% of prescriptions dispensed in the United States.
The committee’s investigation found that these managers maintain preferred drug lists that favor higher-priced brand-name medications over less expensive alternatives. An example highlighted in the report includes internal communications from Cigna that advised against using cheaper substitutes for Humira, a drug for arthritis and autoimmune diseases that costs around $90,000 annually, despite the availability of a biosimilar at half the price.
Additionally, the report noted that Express Scripts informed patients that they would incur higher out-of-pocket costs when filling prescriptions at local pharmacies compared to obtaining a three-month supply through its mail-order service. This approach effectively limits patient pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that “increasing vertical integration and concentration” has given the six largest PBMs control over nearly 95% of all prescriptions in the U.S. The FTC expressed concern that these dominant PBMs wield substantial influence over Americans’ access to and affordability of medications, creating potential conflicts of interest by favoring their own affiliated businesses.
FTC Chair Lina M. Khan indicated that these findings reveal how middlemen are driving up costs for patients seeking cancer drugs, resulting in additional revenue exceeding $1 billion for these intermediaries.