A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting access to them. This report follows a 32-month investigation and comes ahead of a hearing involving executives from the largest PBM firms in the country.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies on behalf of health plans. They also determine the out-of-pocket expenses faced by patients.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage roughly 80% of all prescriptions in the country.
According to the committee’s findings, PBMs have established lists of preferred drugs that tend to favor high-priced brand-name medications over less expensive alternatives. For instance, the report highlighted communications from Cigna employees that discouraged selecting cheaper options for Humira, a medication for arthritis and other autoimmune diseases, which was priced at $90,000 annually, despite the availability of a biosimilar that cost half that amount.
The report also indicated that Express Scripts informed patients that filling prescriptions at local pharmacies would be more expensive than ordering a three-month supply through its affiliated mail-order service. This practice effectively restricts patient options regarding pharmacy choice.
In a related report released earlier this month, the U.S. Federal Trade Commission (FTC) stated that increased vertical integration and market concentration have allowed the six largest PBMs to control nearly 95% of all U.S. prescriptions.
The FTC described the situation as concerning, noting that leading PBMs have gained substantial power over Americans’ access to and affordability of prescription medications. The report further pointed out that this integrated system may incentivize PBMs to prioritize their own affiliated businesses, posing conflicts of interest and driving up drug costs for consumers.
FTC Chair Lina M. Khan emphasized that these findings indicate that middlemen are “overcharging patients for cancer drugs,” contributing to excess revenues of more than $1 billion.