A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are guiding patients toward more expensive medications while restricting their choices of where to obtain those drugs.
The report, discussed in the Wall Street Journal, is the result of a 32-month investigation by the committee and coincides with an upcoming hearing featuring executives from the nation’s largest PBMs.
PBMs serve as intermediaries for prescription drug plans offered by health insurers, negotiating with pharmaceutical companies to determine drug prices and setting out-of-pocket costs for patients. The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—handle around 80% of U.S. prescriptions.
According to the committee’s findings, PBMs often create preferred drug lists that favor higher-cost brand-name drugs over more affordable alternatives. The report highlights internal communications from Cigna that urged staff to recommend the brand-name drug Humira, which was priced at $90,000 annually, instead of a biosimilar available for about half that cost.
Additionally, Express Scripts reportedly informed patients that those seeking prescriptions from local pharmacies could expect to pay more than if they obtained a three-month supply through its affiliated mail-order service, thereby limiting pharmacies that patients could choose.
Earlier this month, the U.S. Federal Trade Commission released a similar report, stating that the six largest PBMs now manage nearly 95% of all filled prescriptions in the U.S. The FTC expressed concern over the significant power these PBMs wield regarding access to and affordability of prescription medications, as well as potential conflicts of interest that could disadvantage independent pharmacies and contribute to higher drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen are “overcharging patients for cancer drugs,” generating an additional $1 billion in revenue.