A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are pushing patients toward more costly medications and restricting their pharmacy options. This report, highlighted by the Wall Street Journal, follows a 32-month investigation by the committee in anticipation of a hearing featuring executives from the largest PBMs.
PBMs act as intermediaries for prescription drug plans, negotiating prices with pharmaceutical companies on behalf of health insurers and determining the out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control approximately 80% of prescriptions filled in the U.S.
The committee identified that these PBMs favor more expensive brand-name drugs over cheaper alternatives in their preferred drug lists. For instance, emails from Cigna employees revealed dissuasion against using lower-cost alternatives to Humira, an arthritis treatment priced at $90,000 annually, despite the availability of a biosimilar at half the cost.
Additionally, Express Scripts informed patients that they would incur higher costs if they chose to fill prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service. This practice limits patients’ pharmacy choices, the report indicates.
A similar analysis by the U.S. Federal Trade Commission, released earlier this month, identified that the largest six PBMs now manage nearly 95% of all prescriptions in the U.S. The FTC expressed concern regarding the significant power PBMs hold over Americans’ access to affordable medications, stating that this vertical integration may create conflicts of interest that disadvantage independent pharmacies.
FTC Chair Lina M. Khan pointed out that these middlemen are overcharging patients specifically for cancer treatments, generating over $1 billion in additional revenue.