A report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while limiting their pharmacy options. The Wall Street Journal reviewed the 32-month investigation ahead of an upcoming hearing featuring executives from major PBMs.
PBMs serve as intermediaries for prescription drug plans, negotiating prices with pharmaceutical companies and determining patient out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage around 80% of the nation’s prescriptions.
The committee discovered that PBMs favor more expensive brand-name drugs over affordable alternatives. The report includes instances from Cigna’s staff discouraging the use of less expensive alternatives to Humira, a drug for arthritis and autoimmune conditions, which costs approximately $90,000 annually, despite the availability of a biosimilar at half that price.
Furthermore, Express Scripts reportedly informed patients that they would be charged more at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service, thereby restricting patient choice regarding pharmacy options.
In a similar vein, the U.S. Federal Trade Commission (FTC) published a report indicating that the six largest PBMs control nearly 95% of all prescriptions in the U.S. The findings highlight concerns over the significant influence PBMs have on Americans’ access to affordable medications. The FTC also noted potential conflicts of interest with vertically integrated PBMs favoring their own affiliated businesses, potentially disadvantaging independent pharmacies and driving up drug prices.
FTC Chair Lina M. Khan emphasized that these findings reflect that PBMs are overcharging patients for cancer treatments, contributing an excess of $1 billion in additional revenue for themselves.