A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications and restricting their access to pharmacies. This report, which was reviewed by the Wall Street Journal, is the outcome of a 32-month investigation conducted by the committee ahead of a hearing involving executives from major PBM companies.
PBMs function as intermediaries in managing prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket expenses for patients. The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—oversee approximately 80% of all prescriptions written in the country.
The committee’s findings indicate that PBMs are developing lists of preferred medications that favor costly brand-name drugs instead of lower-priced alternatives. The report highlights emails from Cigna staff that recommended against the use of cheaper substitutes for Humira, a treatment for arthritis and autoimmune conditions, which was priced at $90,000 annually, despite available biosimilars costing half that amount.
Moreover, the investigation uncovered that Express Scripts informed patients that they would incur higher costs at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order pharmacy. This practice restricts patients’ choices regarding where to fill their prescriptions.
Additionally, a report from the U.S. Federal Trade Commission (FTC) published earlier this month echoes these concerns, noting that increased consolidation has allowed the six largest PBMs to exert control over nearly 95% of prescriptions in the U.S. The FTC’s findings suggest that these powerful PBMs significantly influence Americans’ access to affordable medications, potentially creating conflicts of interest by preferring their own affiliated businesses, which can disadvantage independent pharmacies and elevate drug costs.
FTC Chair Lina M. Khan stated that these findings demonstrate that PBMs are “overcharging patients for cancer drugs,” generating excess revenue exceeding $1 billion.