A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting access to alternatives. This investigation, which spanned over 32 months, precedes a hearing involving executives from the largest PBMs in the nation.
PBMs serve as third-party administrators for prescription drug plans linked to health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket costs for patients. The top three PBMs in the U.S. — Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark — control approximately 80% of prescriptions filled across the country.
The committee’s findings indicate that PBMs have developed lists of preferred medications that prioritize higher-priced brand-name drugs instead of more affordable options. The report highlights communications from Cigna staff that advised against the use of cheaper alternatives to Humira, a medication for arthritis and autoimmune disorders costing around $90,000 annually, despite more affordable biosimilars being available.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through their associated mail-order pharmacy, thus limiting patient choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report stating that increased consolidation in the industry has led the six largest PBMs to manage nearly 95% of all U.S. prescriptions. The FTC expressed concern that these dominant PBMs possess considerable influence over patients’ access to affordable medications, potentially prioritizing their own business interests and elevating prescription drug prices.
FTC Chair Lina M. Khan criticized the role of these intermediaries, asserting that they are “overcharging patients for cancer drugs,” resulting in additional revenue exceeding $1 billion.