A recent report from the House Committee on Oversight and Accountability highlights that pharmacy benefit managers (PBMs) are directing patients towards pricier medications and restricting their access to pharmacies. This finding emerged from a lengthy 32-month investigation, leading up to a committee hearing involving executives from the largest PBM companies in the U.S.
PBMs, which serve as third-party administrators for prescription drug plans, play a crucial role by negotiating prices between pharmaceutical companies and health insurers, in addition to determining out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage about 80% of prescriptions in the United States.
The committee’s findings revealed that these PBMs often create preferred drug lists that favor higher-priced branded drugs over more economical alternatives. An example cited includes communications from Cigna discouraging the use of less expensive options for Humira, an arthritis medication priced at $90,000 annually, despite the availability of biosimilars at half that cost.
Additionally, the committee noted that Express Scripts informed patients they would face higher costs using local pharmacies compared to purchasing a three-month supply via its mail-order service, thereby limiting pharmacy choices for patients.
A similar report from the U.S. Federal Trade Commission (FTC) earlier this month indicated that the six largest PBMs control nearly 95% of all prescriptions filled in the country due to increasing consolidation. The FTC’s interim report expressed concerns over the substantial power these PBMs hold, potentially impeding American access to affordable medications. It also flagged a conflict of interest arising from the vertical integration of PBMs that could disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen are significantly increasing costs for patients, especially regarding cancer treatments, resulting in additional revenues exceeding $1 billion.