A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients toward costlier medications and restricting their pharmacy choices. This report, which was reviewed by the Wall Street Journal, follows a 32-month investigation ahead of a hearing involving major PBM executives.
PBMs serve as intermediaries for prescription drug plans managed by health insurers, negotiating prices with pharmaceutical companies and establishing the out-of-pocket costs faced by patients. The three largest PBMs in the country—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—handle around 80% of U.S. prescriptions.
Findings in the report indicate that PBMs have developed preferred drug lists that prioritize higher-cost brand-name drugs over less expensive alternatives. One notable example referenced in the report is the case of Humira, an arthritis treatment that costs approximately $90,000 per year at that time, with at least one biosimilar version available for half that price. Emails from Cigna employees reportedly discouraged the use of these cheaper alternatives.
Additionally, the report highlights that Express Scripts informed patients that they would incur higher costs if they opted to fill prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service. This practice effectively narrows patient choices regarding where to obtain their medications.
A similar report released by the U.S. Federal Trade Commission earlier this month states that the six largest PBMs control nearly 95% of all prescriptions filled in the United States, a trend that raises concerns. The FTC’s findings suggest that leading PBMs wield significant influence over Americans’ access to affordable prescription drugs, potentially favoring their own affiliated businesses. This setup could create conflicts of interest that disadvantage independent pharmacies and raise prescription costs overall.
FTC Chair Lina M. Khan noted that these practices are leading to inflated charges for cancer medications, resulting in over $1 billion in extra revenue for these middlemen.