A new report from the House Committee on Oversight and Accountability indicates that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications and restricting their pharmacy options.
The report, reported by the Wall Street Journal, resulted from a 32-month investigation conducted by the committee in anticipation of a hearing involving executives from the country’s largest PBMs.
PBMs serve as intermediaries that administer prescription drug plans for health insurers, negotiating payments for medications with pharmaceutical companies while also determining patients’ out-of-pocket costs. The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage around 80% of all prescriptions filled.
The committee’s findings reveal that PBMs have developed preferred drug lists that favor higher-priced brand-name medications over lower-cost alternatives. For instance, the report includes emails from Cigna staff that discouraged the prescription of less expensive alternatives to Humira, an arthritis treatment priced at $90,000 annually, despite the availability of a biosimilar option that was half as expensive.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs when filling prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service. This practice limits patients’ choices regarding where they can fill prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, highlighting that rising vertical integration among PBMs has led the six largest firms to control nearly 95% of all prescriptions filled in the country. The FTC expressed concern over the significant influence PBMs wield over Americans’ accessibility to and affordability of prescription medications, describing a system where vertically integrated PBMs may favor their own businesses, potentially harming independent pharmacies and increasing drug costs.
FTC Chair Lina M. Khan noted that the findings reveal that these intermediaries are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.