Pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting their options for where to obtain them, according to a recent report by the House Committee on Oversight and Accountability.
The committee’s findings, shared with the Wall Street Journal, are the result of a 32-month investigation leading up to a scheduled hearing involving top executives from the largest PBMs in the country.
PBMs serve as intermediaries for health insurers in managing prescription drug plans. They negotiate prices with pharmaceutical companies and establish the out-of-pocket expenses that patients face.
The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—control approximately 80% of prescriptions filled in the nation.
The report highlighted that PBMs have developed lists of preferred medications that feature costlier brand-name drugs over less expensive alternatives. For instance, internal communications from Cigna revealed efforts to dissuade the use of a lower-cost biosimilar for Humira, a drug used for treating arthritis and other autoimmune disorders, which previously cost around $90,000 annually.
Additionally, the investigation found that Express Scripts informed patients they would incur higher costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service. This practice constrains patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission released a related report, noting that growing vertical integration among PBMs allows the six largest firms to manage nearly 95% of prescription fills in the United States.
The findings raise serious concerns, as stated by the FTC: “The leading PBMs now exercise significant power over Americans’ ability to access and afford their prescription drugs.” The agency also warned that these vertically integrated PBMs might prioritize their own affiliated entities, leading to conflicts of interest that negatively impact independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen are costing patients more for critical medications, with excess revenues from cancer drug pricing exceeding $1 billion.