Pharmacy benefit managers (PBMs) are directing patients towards more expensive medications while restricting their options for obtaining these drugs, a recent report from the House Committee on Oversight and Accountability reveals.
The committee’s findings, which were shared with the Wall Street Journal, stem from a 32-month investigation conducted ahead of a hearing featuring executives from the nation’s top PBMs.
PBMs serve as intermediaries for prescription drug plans within health insurance, negotiating prices with pharmaceutical companies and determining the out-of-pocket costs patients are required to pay.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of the prescriptions dispensed across the country.
The report indicates that PBMs have established lists favoring higher-priced brand-name drugs over more affordable alternatives. For instance, it includes communication from Cigna employees advising against using cheaper substitutes for Humira, an arthritis treatment costing $90,000 annually, when a biosimilar was available for approximately half that amount.
Additionally, the committee pointed out that Express Scripts informed patients that they would incur higher costs at their local pharmacy compared to obtaining a three-month supply through its affiliated mail-order service, effectively limiting patient choice in pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report highlighting that rising vertical integration and market concentration have allowed the six largest PBMs to control nearly 95% of all prescriptions filled in the U.S.
The findings raise significant concerns, with the FTC stating that leading PBMs hold substantial power over Americans’ access to and affordability of their prescription medications. This situation creates a framework in which vertically integrated PBMs may favor their own affiliated businesses, leading to conflicts of interest that could harm independent pharmacies and drive up drug costs.
FTC Chair Lina M. Khan emphasized that the report shows these intermediaries are “overcharging patients for cancer drugs,” resulting in more than $1 billion in additional revenue for them.