A new report from the House Committee on Oversight and Accountability indicates that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications while restricting access to more affordable options. This report, which was seen by the Wall Street Journal, comes after a 32-month investigation by the committee in anticipation of a hearing featuring executives from the country’s largest PBMs.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket costs. The three largest PBMs, Express Scripts, OptumRx (a subsidiary of UnitedHealth Group), and Caremark from CVS Health, oversee nearly 80% of prescriptions filled in the United States.
The committee’s findings reveal that PBMs often compile lists of preferred drugs that focus on more expensive brand-name medications, sidelining cheaper alternatives. For instance, the report references communications from Cigna that discouraged the use of lower-cost substitutes for Humira, an arthritis medication that costs around $90,000 annually, despite a biosimilar costing half that amount being available.
Additionally, the report highlights how Express Scripts informed patients they would incur higher costs if they chose to fill their prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, thus limiting patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission released a similar report, noting that the increasing vertical integration among the largest PBMs has led them to manage approximately 95% of all prescriptions in the United States. The FTC’s findings raised concerns, stating that these PBMs have significant leverage over patients’ access to and affordability of medications and that their affiliations create potential conflicts of interest. FTC Chair Lina M. Khan emphasized that these middlemen are “overcharging patients for cancer drugs,” resulting in additional revenue exceeding $1 billion.