A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting their choices for obtaining them. This report, which emerged after a 32-month investigation, precedes a hearing on PBMs featuring executives from the largest companies in the sector.
PBMs function as third-party administrators for prescription drug plans on behalf of health insurers, negotiating prices with drug manufacturers and determining the 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—manage around 80% of the country’s prescriptions.
According to the report, PBMs have been creating lists of preferred medications that prioritize higher-priced brand-name drugs over more economical alternatives. An example highlighted is the case of Cigna, which discouraged the use of more affordable options for Humira, a medication for arthritis and autoimmune conditions that costs around $90,000 annually, while cheaper biosimilars were available for about half that price.
Additionally, Express Scripts reportedly informed patients that they would incur higher costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply through their affiliated mail-order service, consequently limiting patients’ pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that the consolidation among PBMs has given the largest six companies control over nearly 95% of all prescriptions filled in the U.S. The FTC reported that this concentration empowers PBMs to dominate access to affordable prescription medications and creates a situation where integrated PBMs may favor their own affiliated businesses, leading to potential conflicts of interest that could disadvantage independent pharmacies and inflate drug costs.
FTC Chair Lina M. Khan expressed concern over the findings, noting that these intermediaries are “overcharging patients for cancer drugs,” resulting in excess revenue exceeding $1 billion.