According to a recent report from the House Committee on Oversight and Accountability, pharmacy-benefit managers (PBMs) are directing patients towards higher-priced medications while restricting their choices for obtaining them. This report follows a 32-month investigation and comes just before a hearing on PBMs, where executives from the largest management firms will be present.
PBMs act as intermediaries for prescription drug plans offered by health insurers. They negotiate with drug manufacturers regarding the prices health plans pay for medications and determine out-of-pocket costs for patients.
The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (a CVS Health company)—control nearly 80% of prescriptions dispensed in the country.
The investigation revealed that PBMs have constructed lists favoring higher-priced brand-name drugs over more affordable alternatives. For instance, the committee highlighted emails from Cigna staff that discouraged using cheaper options for Humira, a costly treatment for arthritis and other autoimmune diseases priced at $90,000 annually, despite the availability of a biosimilar at about half that cost.
Moreover, the committee pointed out that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to purchasing a three-month supply through its affiliated mail-order service, thereby limiting patients’ pharmacy choices.
Earlier this month, the Federal Trade Commission (FTC) released a similar report indicating that increased consolidation and vertical integration have allowed the six largest PBMs to oversee approximately 95% of all prescriptions filled in the U.S.
The findings are concerning, with the FTC noting that the leading PBMs hold substantial influence over Americans’ access to and affordability of prescription drugs. This situation raises potential conflicts of interest as vertically integrated PBMs may favor their own affiliated businesses, potentially harming independent pharmacies and driving up drug costs. FTC Chair Lina M. Khan pointed out that these middlemen are “overcharging patients for cancer drugs,” thus generating over $1 billion in additional revenue.