Pharmacy-benefit managers (PBMs) are directing patients towards more expensive medication options while restricting their access to certain pharmacies, as outlined 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 inquiry by the committee in anticipation of a hearing involving the executives of the country’s leading PBMs.
PBMs serve as intermediaries that manage prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining the out-of-pocket expenses for patients. The three largest PBMs in the United States—Express Scripts, OptumRx (a division of UnitedHealth Group), and Caremark (a division of CVS Health)—collectively control around 80% of the nation’s prescription market.
According to the committee’s findings, these managers maintain lists of preferred drugs that often prioritize higher-priced brand-name medications over more affordable generic options. For instance, the report references communications from Cigna employees advising against using less expensive alternatives for Humira, a drug for arthritis and other autoimmune diseases that was priced at $90,000 annually, despite the availability of biosimilars at half the cost.
Additionally, the committee discovered that Express Scripts informed patients that filling prescriptions at local pharmacies would be more expensive than obtaining a three-month supply through its affiliated mail-order service. This practice effectively restricts patients’ choices regarding which pharmacies they can use.
In a related finding, the U.S. Federal Trade Commission (FTC) released a similar report earlier this month, indicating that the growing concentration and integration within the industry has allowed the six largest PBMs to manage almost 95% of all prescriptions filled in the U.S.
The FTC expressed concern over the implications of these findings. “The leading PBMs now possess substantial influence over Americans’ access to and affordability of prescription medications,” the report stated. It noted a potential scenario where integrated PBMs might prioritize their own businesses, creating conflicts of interest that could harm independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan indicated that the findings demonstrate how these middlemen are “overcharging patients for cancer drugs,” resulting in over $1 billion in additional revenue for them.