Pharmacy-benefit managers (PBMs) are directing patients towards costlier medications and restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability.
The report, which followed a 32-month investigation ahead of a hearing featuring executives from the largest PBMs in the country, reveals that these managers, acting as third-party administrators for prescription drug plans, negotiate prices with pharmaceutical companies and determine patient out-of-pocket costs.
The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of the U.S. prescription market.
The findings indicate that PBMs have fostered lists of preferred medications that favor pricier brand-name drugs over more affordable generic options. For instance, emails from Cigna staff highlighted a discouragement against using cheaper alternatives to Humira, a medication for arthritis and other autoimmune diseases, which at one point cost $90,000 annually. A biosimilar for this medication was available at half that cost.
The committee further found that Express Scripts informed patients they would incur higher costs by filling prescriptions at their neighborhood pharmacies compared to obtaining a three-month supply through their affiliated mail-order pharmacy, thereby limiting patient choice.
Additionally, a report by the U.S. Federal Trade Commission (FTC) earlier this month echoed these concerns, stating that increasing consolidation has allowed the six largest PBMs to manage nearly 95% of prescriptions filled in the U.S.
The FTC’s findings are alarming, highlighting that leading PBMs wield considerable influence over American patients’ access to affordable medications. This situation has led to a system where vertically integrated PBMs may favor their own affiliated businesses, resulting in conflicts of interest that can diminish options for unaffiliated pharmacies and elevate drug costs. FTC Chair Lina M. Khan emphasized that these middlemen are significantly overcharging patients for cancer drugs, generating over $1 billion in additional revenue.