A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting their choice of pharmacies. This report follows a 32-month investigation and comes ahead of a hearing involving executives from the country’s largest PBMs.
PBMs serve as third-party administrators for prescription drug plans, negotiating costs with pharmaceutical companies on behalf of health plans and determining out-of-pocket expenses for patients. The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control roughly 80% of all prescriptions.
The committee’s findings indicate that PBMs have established preferred drug lists that favor higher-priced brand-name medications over more affordable options. An example highlighted in the report involves Cigna employees advising against lower-cost alternatives to Humira, an arthritis treatment priced at $90,000 annually, despite the availability of a biosimilar at half the cost.
Additionally, Express Scripts allegedly informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to ordering a three-month supply through its affiliated mail-order service, effectively limiting patient choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) released an interim report that echoed similar concerns. It noted that increased concentration and vertical integration have allowed the six largest PBMs to manage nearly 95% of U.S. prescriptions.
The FTC expressed concern about the significant influence PBMs have over Americans’ access to and affordability of prescription drugs, warning that vertically integrated PBMs may prioritize their affiliated businesses, thereby creating conflicts of interest that harm independent pharmacies and drive up medication costs. FTC Chair Lina M. Khan pointed out that these middlemen have been overcharging cancer patients, generating an excess revenue of over $1 billion.