A recent report from the House Committee on Oversight and Accountability has highlighted concerns regarding pharmacy-benefit managers (PBMs), indicating that they may be directing patients towards more expensive medications while restricting their options for pharmacies. This report follows a 32-month investigation and precedes a hearing involving executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans, negotiating prices with pharmaceutical companies and setting out-of-pocket costs for patients. The three largest PBMs—Express Scripts, OptumRx (a division of UnitedHealth Group), and Caremark (part of CVS Health)—control about 80% of all prescriptions in the U.S.
The committee’s findings suggest that PBMs are creating preferred drug lists that favor higher-priced brand-name medications over cheaper alternatives. For instance, communications from Cigna reported in the report discouraged the use of lower-cost substitutes for Humira, a drug treating arthritis and autoimmune conditions, which had a cost of $90,000 per year, despite the availability of biosimilars at half that price.
Additionally, Express Scripts reportedly informed patients that they would incur higher costs when filling prescriptions at local pharmacies compared to ordering a three-month supply from their affiliated mail-order service, effectively limiting patients’ pharmacy options.
Earlier this month, a similar report was released by the U.S. Federal Trade Commission (FTC), which stated that growing consolidation and vertical integration have allowed the six largest PBMs to control nearly 95% of all prescriptions in the United States.
The FTC expressed grave concerns, stating, “The leading PBMs now exercise significant power over Americans’ ability to access and afford their prescription drugs.” This situation leads to potential conflicts of interest, as these PBMs may prioritize their own businesses over unaffiliated pharmacies, thus raising prescription drug costs for patients. FTC Chair Lina M. Khan noted that these middlemen are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.