A recent report from the House Committee on Oversight and Accountability has found that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications and restricting their pharmacy options. The report, reviewed by the Wall Street Journal, is the result of a 32-month investigation and comes ahead of a hearing featuring executives from the country’s largest PBMs.
PBMs act as intermediaries for health insurers, negotiating drug prices with pharmaceutical firms and determining patients’ out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of the nation’s prescriptions.
The committee’s findings indicate that PBMs have established preferred drug lists that favor high-priced brand-name medications over more affordable alternatives. For instance, emails from Cigna personnel discouraged opting for cheaper substitutes for Humira, a costly treatment for arthritis and autoimmune disorders, which was priced at $90,000 annually. A biosimilar was available for approximately half that cost.
Additionally, the report mentions that Express Scripts informed patients that obtaining a prescription locally would be more expensive than acquiring a three-month supply through its mail-order service, thus limiting patients’ choices of pharmacies.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report, highlighting that the six largest PBMs now account for nearly 95% of all prescriptions filled across the country. The FTC expressed concerns over the significant influence that leading PBMs wield over patients’ access to and affordability of necessary medications. The report points out that vertically integrated PBMs might prioritize their affiliated businesses, potentially disadvantaging independent pharmacies and elevating prescription costs.
FTC Chair Lina M. Khan underscored that the findings reveal that these intermediaries may be overcharging patients for cancer treatments, leading to over $1 billion in additional revenue for the PBMs.