A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are guiding patients towards more expensive medications while restricting their pharmacy options.
The report, which was seen by the Wall Street Journal, followed a 32-month investigation and was released ahead of a hearing involving executives from the country’s largest PBMs. These entities function as third-party administrators for prescription drug plans tied to health insurers, negotiating prices with pharmaceutical companies, and determining patients’ out-of-pocket expenses.
The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—control about 80% of the prescriptions dispensed in the country.
According to the committee’s findings, PBMs maintain lists of preferred drugs that prioritize higher-priced brand-name medications over less expensive alternatives. An example provided in the report includes internal communications from Cigna that advised against using cheaper substitutes for Humira, a treatment that costs around $90,000 annually, despite a biosimilar option being available for half that price.
The investigation also showed that Express Scripts informed patients that they would incur higher costs if they filled a prescription at their local pharmacies compared to getting a three-month supply from their affiliated mail-order service. This practice effectively restricts patients’ pharmacy choices.
Additionally, a report earlier this month from the U.S. Federal Trade Commission echoed these concerns, highlighting that the six largest PBMs manage nearly 95% of all prescriptions in the U.S. The FTC stated that the dominant role of leading PBMs significantly affects Americans’ access to affordable medications, creating a system rife with conflicts of interest that can disadvantage independent pharmacies and inflate prescription drug prices.
FTC Chair Lina M. Khan pointed out that these middlemen are allegedly overcharging patients for cancer medications, contributing to excess revenue exceeding $1 billion.