According to a recent report from the House Committee on Oversight and Accountability, pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting their options for obtaining these drugs. This report comes after a 32-month investigation and precedes a hearing involving executives from major PBM companies.
PBMs act as intermediaries within the prescription drug market for health insurers, negotiating prices with pharmaceutical companies and determining the out-of-pocket costs that patients face. The three largest PBMs in the United States—Express Scripts, OptumRx (owned by UnitedHealth Group), and Caremark (part of CVS Health)—control roughly 80% of all prescriptions.
The committee’s findings revealed that these managers have established preferred drug lists that often prioritize higher-priced brand-name medications over more affordable alternatives. An example cited in the report involved internal communications from Cigna, which advised against using less expensive alternatives to Humira, a medication for arthritis that was priced at $90,000 annually, when a biosimilar was available for half that cost.
Furthermore, Express Scripts informed patients that they would incur higher costs by using their local pharmacy rather than obtaining a three-month supply through its own mail-order service, effectively limiting their pharmacy options.
A similar report was issued earlier this month by the U.S. Federal Trade Commission (FTC), which noted that the six largest PBMs now oversee almost 95% of prescriptions filled in the country due to increasing consolidation and vertical integration in the industry.
The FTC’s findings raised concerns regarding the significant influence PBMs exert over patients’ access to and affordability of prescription medications. The report highlighted risks associated with integrated PBMs favoring their own businesses, leading to potential disadvantages for independent pharmacies and overall higher drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen are contributing to increased charges for patients receiving cancer treatments, generating additional revenues exceeding $1 billion.