According to a recent report by the House Committee on Oversight and Accountability, pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their choices of pharmacies. This report, reviewed by the Wall Street Journal, is the result of a 32-month investigation leading up to a hearing featuring executives from the country’s largest PBMs.
PBMs serve as intermediaries for prescription drug plans, negotiating prices with pharmaceutical companies on behalf of health insurers and determining out-of-pocket costs for patients. Currently, the three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—handle about 80% of all prescriptions.
The committee’s findings indicate that these PBMs maintain lists of preferred drugs that favor higher-priced brand-name medications over more affordable alternatives. The report highlights instances, such as correspondence from Cigna discouraging the use of less expensive substitutes for the arthritis treatment Humira, which was priced at $90,000 per year despite the availability of a biosimilar at about half that cost.
Additionally, the report revealed that Express Scripts informed patients they would incur more costs by obtaining prescriptions from their local pharmacies than by ordering a three-month supply through its affiliated mail-order service. This practice severely limited patients’ pharmacy options.
A similar report from the U.S. Federal Trade Commission (FTC) released earlier this month noted that an increase in vertical integration has allowed the six largest PBMs to manage close to 95% of all prescriptions in the U.S. The FTC’s interim findings raised concerns about the significant influence these PBMs hold over patients’ access to affordable medications, pointing out that their practices may lead to conflicts of interest that ultimately disadvantage independent pharmacies and elevate drug prices.
FTC Chair Lina M. Khan stated that the investigation reveals that these middlemen are profiting from overcharging patients for cancer treatments, resulting in additional revenue exceeding $1 billion.