A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their pharmacy options. This report follows a comprehensive 32-month investigation and precedes a hearing involving executives from major PBMs.
PBMs serve as intermediaries managing prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket costs. The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of the nation’s prescriptions.
The findings indicate that PBMs maintain preferred drug lists that prioritize higher-priced brand-name medications over more affordable alternatives. For instance, emails from Cigna highlighted discouragement of cheaper options for Humira, a drug used for treating arthritis and other autoimmune conditions, which had a yearly cost of $90,000 despite the availability of a biosimilar for half that price.
Additionally, the committee noted that Express Scripts informed patients they would pay significantly more at local pharmacies than through its affiliated mail-order service, thereby limiting their pharmacy choices.
A concurrent report from the U.S. Federal Trade Commission (FTC) stated that a growing concentration in the PBM market allows the six largest PBMs to control nearly 95% of prescriptions filled in the country. The FTC expressed concerns over the power these PBMs wield over prescription drug access and affordability, suggesting that their vertical integration creates conflicts of interest that disadvantage independent pharmacies and elevate drug costs.
FTC Chair Lina M. Khan emphasized that these middlemen are imposing higher charges on patients for cancer medications, translating into over $1 billion in additional revenue for them.