A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) may be pushing patients toward more expensive medications and restricting their pharmacy options. The report, which was reviewed by the Wall Street Journal, is the culmination of a 32-month investigation ahead of a hearing featuring executives from the nation’s largest PBMs.
PBMs act as intermediaries for health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket costs. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—account for about 80% of prescriptions filled in the U.S.
The committee’s findings indicate that PBMs have implemented preferred drug lists that often elevate pricier brand-name medications over more affordable alternatives. For instance, the report referenced internal communications from Cigna that discouraged considering lower-cost options for Humira, a drug for arthritis and other autoimmune conditions which had an annual cost of around $90,000. In contrast, at least one biosimilar was available for about half the price.
Additionally, the report notes that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to ordering a three-month supply from its affiliated mail-order service, thereby restricting patients’ choice of pharmacy.
Earlier this month, the U.S. Federal Trade Commission released a similar report stating that the consolidation among the six largest PBMs allows them to oversee nearly 95% of all prescriptions in the country. The FTC’s findings raise concerns about PBMs’ significant influence over Americans’ access to affordable medications. It also highlighted how vertically integrated PBMs might favor their own businesses, potentially disadvantaging independent pharmacies and increasing drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen are “overcharging patients for cancer drugs,” which has generated additional revenues exceeding $1 billion.