Pharmacy-benefit managers (PBMs) are directing patients towards pricier medications while restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability.
The investigation, which spanned 32 months, was conducted ahead of a hearing involving executives from the country’s largest PBMs, as detailed in a report reviewed by the Wall Street Journal.
PBMs act as third-party administrators for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket costs.
The leading three PBMs—Express Scripts, OptumRx (UnitedHealth Group), and Caremark (CVS Health)—control around 80% of U.S. prescriptions.
The committee’s findings revealed that PBMs maintain lists of preferred medications that often highlight higher-priced brand-name drugs over more affordable alternatives. For instance, emails from Cigna staff were found to discourage the use of lower-cost options for Humira, an arthritis treatment with an annual price tag of $90,000, despite a biosimilar being available for half that cost.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs when using their local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, thereby limiting patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that “increasing vertical integration and concentration has allowed the six largest PBMs to manage nearly 95% of all prescriptions filled in the United States.”
The FTC raised alarms over the situation, stating, “The leading PBMs now wield considerable power over Americans’ access to and affordability of prescription drugs.” The report also highlighted that the vertically integrated PBMs seem to prioritize their own affiliated businesses, creating conflicts of interest that could disadvantage independent pharmacies and raise prescription costs.
FTC Chair Lina M. Khan emphasized that the findings reveal how these intermediaries are “overcharging patients for cancer drugs,” leading to additional revenue exceeding $1 billion for the companies involved.