Pharmacy benefit managers (PBMs) are directing patients towards more expensive medications and restricting their options for obtaining them, according to a recent report from the House Committee on Oversight and Accountability.
This report, which was reviewed by the Wall Street Journal, came after an extensive 32-month investigation preceding a hearing on PBMs that involved leaders from the country’s major PBMs.
PBMs act as intermediaries for prescription drug plans administered by health insurers. They negotiate prices with pharmaceutical companies and determine out-of-pocket costs for patients.
The largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—control approximately 80% of prescriptions in the country.
The committee’s findings revealed that PBMs compile lists of favored medications that often include costlier brand-name drugs over cheaper alternatives. In one instance, the report referenced communications from Cigna staff that discouraged opting for less expensive alternatives to Humira, an arthritis treatment that was $90,000 annually, despite the existence of a biosimilar available for half that cost.
Additionally, the committee discovered 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 associated mail-order service, ultimately limiting patient pharmacy choices.
A similar report from the U.S. Federal Trade Commission (FTC) released earlier this month indicated that “increasing vertical integration and concentration” has allowed the six leading PBMs to manage nearly 95% of all U.S. filled prescriptions.
The FTC expressed concern over these findings, noting that the dominant PBMs possess substantial control over Americans’ access to and affordability of prescription medications. This dynamic fosters an environment where integrated PBMs may favor their own affiliated companies, leading to potential conflicts of interest that disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan highlighted that the middlemen are “overcharging patients for cancer drugs,” generating additional revenue exceeding $1 billion.