Pharmacy-benefit managers (PBMs) are allegedly directing patients towards more expensive medications and restricting their options for pharmacies, as revealed in a recent report by the House Committee on Oversight and Accountability.
The report, which was seen by the Wall Street Journal, is the result of a 32-month investigation conducted by the committee in advance of a hearing featuring executives from the largest PBMs in the country.
PBMs act as intermediaries that manage prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket expenses for patients. The three top PBMs—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—control roughly 80% of all U.S. prescriptions.
According to the committee’s findings, these PBMs have developed lists of preferred drugs that favor higher-priced brand-name medications over more affordable options. The report highlighted internal communications from Cigna that discouraged the use of less expensive alternatives to Humira, which costs around $90,000 annually, despite the availability of a biosimilar at half that price.
The committee also noted that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service, thereby limiting patient choice in pharmacy selection.
A similar report from the U.S. Federal Trade Commission (FTC) released earlier this month indicated that the top six PBMs manage nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern over the significant influence these PBMs have on Americans’ access to affordable medications, noting how this system allows vertically integrated PBMs to prefer their own branches, which can harm independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan remarked that the findings indicate that these middlemen are “overcharging patients for cancer drugs,” resulting in an additional revenue stream exceeding $1 billion.