Pharmacy-benefit managers (PBMs) are reportedly directing patients toward higher-cost medications and restricting the pharmacies where they can fill prescriptions, as revealed in a recent report from the House Committee on Oversight and Accountability.
The report, which was reviewed by the Wall Street Journal, follows a 32-month investigation by the committee in anticipation of a hearing that will include executives from the nation’s largest PBMs.
PBMs function as intermediaries for health insurers, managing prescription drug plans. They negotiate prices with pharmaceutical companies and establish the out-of-pocket costs consumers face for medications.
The three largest PBMs in the U.S.—Express Scripts, OptumRx (a part of UnitedHealth Group), and CVS Health’s Caremark—control around 80% of all U.S. prescriptions.
The committee’s findings indicate that PBMs create preferred drug lists that favor more expensive brand-name medications over more affordable options. For instance, emails from Cigna employees discouraged the use of less costly alternatives to Humira, a drug used to treat arthritis and other autoimmune disorders that had an annual price tag of $90,000, while at least one biosimilar was available for approximately half that amount.
Additionally, the committee discovered that Express Scripts informed patients that filling their prescriptions at a local pharmacy would lead to higher costs compared to obtaining a three-month supply from their mail-order pharmacy. This practice appears to restrict patients’ pharmacy options.
A similar report was released by the U.S. Federal Trade Commission (FTC) earlier this month, indicating that the largest six PBMs control nearly 95% of all filled prescriptions in the United States. The FTC expressed concerns about this dominance, stating it has given leading PBMs considerable power over access to and affordability of prescription medications. This concentration may also create conflicts of interest, as integrated PBMs might prefer their own affiliated businesses, disadvantaging independent pharmacies and driving up drug costs for patients.
FTC Chair Lina M. Khan underscored the serious implications of these findings, noting that PBMs are “overcharging patients for cancer drugs,” resulting in over $1 billion in additional revenue for them.