Pharmacy benefit managers (PBMs) are directing patients toward costlier medications and restricting access to certain pharmacies, according to a recent report from the House Committee on Oversight and Accountability.
The report, reviewed by the Wall Street Journal, concludes a 32-month investigation by the committee in preparation for a hearing with executives from the nation’s largest PBMs.
PBMs serve as intermediaries for health insurers, managing prescription drug plans. They negotiate prices with pharmaceutical companies and set patient out-of-pocket expenses. Together, the three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—handle around 80% of U.S. prescriptions.
The committee’s findings indicate that PBMs maintain preferred drug lists favoring higher-priced brand-name medications instead of cheaper alternatives. For instance, emails from Cigna employees discouraged opting for more affordable substitutes for Humira, a treatment for arthritis costing approximately $90,000 annually, even though at least one biosimilar alternative was available for half that price.
Additionally, the report mentions that Express Scripts informed patients they would pay more for prescriptions filled at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, which effectively restricted patient choices in pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that increasing consolidation in the PBM industry allows the six largest PBMs to manage nearly 95% of all U.S. prescriptions.
These findings raise serious concerns. The FTC reported that leading PBMs significantly impact Americans’ access and affordability regarding prescription medications. The vertical integration of these companies potentially harms unaffiliated pharmacies and heightens drug costs.
FTC Chair Lina M. Khan noted that the evidence suggests these intermediaries are “overcharging patients for cancer drugs,” resulting in over $1 billion in additional revenue for them.