A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are pushing patients toward more expensive medications and restricting their pharmacy choices.
This report, examined by the Wall Street Journal, is the result of a 32-month investigation ahead of an upcoming hearing involving executives from the country’s leading PBMs.
PBMs act as intermediaries for prescription drug plans offered by health insurers. They negotiate prices with pharmaceutical companies and determine out-of-pocket costs for patients. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control roughly 80% of U.S. prescriptions.
The committee’s findings indicate that PBMs are favoring higher-priced brand-name drugs over more affordable alternatives in their preferred drug lists. An example highlighted in the report is an email from Cigna staff that discouraged opting for cheaper substitutes for Humira, an arthritis treatment costing approximately $90,000 annually, when a biosimilar was available for half that price.
Additionally, the report claims that Express Scripts informed patients they would incur higher costs by using local pharmacies compared to obtaining a three-month supply through its affiliated mail-order pharmacy, further limiting patient choices.
A similar assertion was made by the U.S. Federal Trade Commission (FTC) in a report released earlier this month, noting that increased consolidation has allowed the six largest PBMs to oversee nearly 95% of prescriptions in the U.S. The FTC expressed concern over the considerable control these PBMs have over access and affordability of medications. The findings also indicate that vertically integrated PBMs may favor their own affiliated businesses, which could harm unaffiliated pharmacies and raise prescription costs.
FTC Chair Lina M. Khan remarked that these middlemen are potentially overcharging patients for cancer medications, resulting in an additional annual revenue exceeding $1 billion.