A new report from the House Committee on Oversight and Accountability reveals that pharmacy benefit managers (PBMs) are directing patients towards more expensive medications and restricting their choices regarding where to fill prescriptions. This report, which was reviewed by the Wall Street Journal, comes after a 32-month investigation and precedes a committee hearing with executives from the major PBM companies.
PBMs act as intermediaries in prescription drug plans for health insurers, negotiating prices with pharmaceutical firms and determining the out-of-pocket costs patients incur. The three largest PBMs in the country—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—are responsible for managing about 80% of all prescriptions filled in the U.S.
The committee’s findings indicate that PBMs create lists of preferred medications that often favor higher-priced brand-name drugs over cheaper generic options. An example highlighted in the report includes internal communications from Cigna discouraging the use of lower-cost alternatives to Humira, a medication for arthritis and autoimmune diseases that was priced at $90,000 annually, while at least one biosimilar was available for half the cost.
Additionally, the report stated that Express Scripts informed patients they would pay more for prescriptions filled at local pharmacies compared to purchasing a three-month supply through its mail-order service, thereby limiting patient choices in pharmacy selection.
In a similar report released earlier this month, the U.S. Federal Trade Commission noted that the increasing market concentration among PBMs allowed the six largest companies to manage nearly 95% of prescriptions filled in the United States. The FTC expressed concern over the significant influence PBMs have on Americans’ access to affordable medications and highlighted conflicts of interest that could arise when PBMs prioritize their own affiliated businesses, potentially disadvantaging independent pharmacies and driving up drug prices.
FTC Chair Lina M. Khan emphasized that the findings illustrate how these intermediaries are overcharging patients for cancer treatments, resulting in excess revenue of over $1 billion.