Pharmacy Benefit Managers (PBMs) are reportedly directing patients toward more costly medications while restricting their access to various pharmacies, according to a recent report from the House Committee on Oversight and Accountability.
This report, which was reviewed by the Wall Street Journal, comes after a thorough 32-month investigation by the committee ahead of a hearing that will involve leaders from the country’s largest PBMs.
PBMs act as intermediaries for health insurers, overseeing prescription drug plans. They negotiate pricing with pharmaceutical firms and determine the out-of-pocket expenses patients face. The three leading PBMs in the United States—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—handle nearly 80% of all prescriptions filled in the country.
The findings of the committee’s report indicate that these PBMs have developed preferred drug lists that prioritize higher-priced brand-name medications over more affordable options. One example highlighted in the report involves Cigna employees who advised against using less expensive alternatives to Humira, a treatment for arthritis and other autoimmune disorders that was priced at $90,000 annually, despite the availability of a biosimilar for half that cost.
Moreover, the committee discovered that Express Scripts informed patients they would incur higher costs if they filled prescriptions at their local pharmacies rather than through its mail-order service. This practice effectively limited patients’ pharmacy choices.
Additionally, a recent interim report from the U.S. Federal Trade Commission (FTC) echoed these concerns, revealing that the six largest PBMs now manage nearly 95% of all prescriptions filled nationwide, resulting in significant leverage over access and affordability of medications for Americans.
The FTC voiced serious concerns regarding this concentration of power, stating that it creates an environment where vertically integrated PBMs may favor their affiliated businesses, generating conflicts of interest that disadvantage independent pharmacies and drive up drug prices. FTC Chair Lina M. Khan remarked that these middlemen are effectively “overcharging patients for cancer drugs,” which has led to an excess revenue of over $1 billion for these entities.