A recent report from the House Committee on Oversight and Accountability has raised concerns about pharmacy-benefit managers (PBMs), claiming they are directing patients toward higher-priced medications and restricting their pharmacy options. This report, which was reviewed by the Wall Street Journal, stems from a 32-month investigation by the committee and precedes a hearing involving executives from the largest PBMs in the nation.
PBMs serve as third-party administrators for prescription drug plans affiliated with health insurers. They negotiate prices with pharmaceutical companies and determine out-of-pocket expenses for patients. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control approximately 80% of the nation’s prescriptions.
According to the findings, PBMs have crafted preferred drug lists that favor more expensive brand-name medications over cheaper alternatives. The report highlights instances where staff at Cigna discouraged the use of lower-cost options for Humira, a drug for arthritis and other autoimmune disorders that cost $90,000 annually, despite the availability of a biosimilar priced at half that amount.
The committee also noted that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, effectively limiting patient choice.
Additionally, a report from the U.S. Federal Trade Commission echoed these concerns, revealing that the top six PBMs now manage nearly 95% of all prescriptions filled in the country. The FTC warned that these developments grant considerable power to PBMs over Americans’ access to affordable medications, fostering an environment where conflicts of interest may disadvantage independent pharmacies and drive up drug prices.
FTC Chair Lina M. Khan expressed alarm over the findings, suggesting that these intermediaries are “overcharging patients for cancer drugs” and reaping over $1 billion in excess revenue as a result.