A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward costlier medications and restricting their access to different pharmacies. This finding follows a 32-month investigation leading up to a hearing that involved executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans on behalf of health insurers, negotiating with pharmaceutical companies about drug pricing and establishing out-of-pocket expenses for patients. The three biggest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control roughly 80% of U.S. prescriptions.
The committee’s report indicates that these PBMs often compile preferred drug lists that favor higher-priced brand-name medications over more affordable options. For instance, it mentions correspondence from Cigna employees that advised against using less expensive alternatives to Humira, a drug priced at $90,000 annually, despite the availability of a biosimilar that costs half as much.
Moreover, the report states that Express Scripts informed patients that they would incur higher costs by obtaining prescriptions from local pharmacies compared to acquiring a three-month supply from its affiliated mail-order service. This strategy effectively limits patients’ choices regarding where to fill their prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) published a similar analysis, noting that increasing consolidation among PBMs has allowed the six largest companies to manage nearly 95% of all prescriptions filled in the U.S.
The implications of these findings are concerning, as the FTC asserts that major PBMs hold substantial power over patients’ access to and affordability of prescription drugs. This situation fosters an environment in which vertically integrated PBMs may prioritize their own affiliated businesses, leading to conflicts of interest that negatively affect independent pharmacies and inflate drug prices.
According to FTC Chair Lina M. Khan, these middlemen are significantly overcharging patients for cancer medications, generating an additional $1 billion in revenue.