Pharmacy benefit managers (PBMs) are reportedly directing patients toward more costly medications while restricting their pharmacy options, as highlighted in a recent report from the House Committee on Oversight and Accountability.
The report, reviewed by the Wall Street Journal, comes after a 32-month investigation by the committee, which is preparing for a hearing that includes executives from the largest PBM companies in the country.
PBMs serve as intermediaries for prescription drug plans offered by health insurers. They negotiate prices with pharmaceutical companies on behalf of health plans and set the out-of-pocket costs that patients must pay.
The three dominant PBMs in the U.S.—Express Scripts, OptumRx, part of UnitedHealth Group, and Caremark, a subsidiary of CVS Health—control around 80% of all prescriptions filled in the nation.
The committee’s findings indicate that PBMs maintain lists of preferred medications that favor higher-priced brand-name drugs over more affordable alternatives. For instance, internal emails from Cigna revealed a preference for Humira, an arthritis treatment costing about $90,000 annually, despite the availability of a biosimilar for half that amount.
Moreover, the committee discovered that Express Scripts informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining three-month supplies from its own mail-order service, thereby limiting patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that increasing consolidation in the industry has allowed the six largest PBMs to control nearly 95% of all prescriptions filled in the country.
These revelations raise serious concerns. The FTC noted that leading PBMs hold considerable influence over Americans’ access to and affordability of prescription drugs. This system allows vertically integrated PBMs to prioritize their own affiliated entities, creating potential conflicts of interest that could harm independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan emphasized that these findings demonstrate how these intermediaries are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.