Pharmacy-benefit managers (PBMs) are reportedly directing patients toward more expensive medications while restricting their access to lower-cost options, according to a recent report from the House Committee on Oversight and Accountability.
The findings, which were shared with the Wall Street Journal, stem from a 32-month investigation and come ahead of a hearing featuring executives from the country’s largest PBMs. These managers serve as intermediaries between health insurers and pharmaceutical companies, negotiating drug pricing and determining patient out-of-pocket costs.
The three largest PBMs in the U.S.— Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control nearly 80% of U.S. prescription medications.
The committee’s report indicates that PBMs have created lists of preferred drugs that tend to favor higher-priced brand-name medications over less costly generics. For instance, emails from Cigna staff reportedly discouraged the use of lower-priced alternatives to Humira, a medication for arthritis and autoimmune conditions that cost $90,000 annually, despite the availability of a biosimilar for significantly less.
Furthermore, the investigation revealed that Express Scripts informed patients that filling a prescription at a local pharmacy would be more expensive than obtaining a three-month supply from its mail-order service, effectively limiting patient choice in selecting pharmacies.
Adding to these concerns, the U.S. Federal Trade Commission (FTC) issued a report earlier this month, highlighting that the six largest PBMs dominate almost 95% of all prescriptions filled in the U.S. The FTC described the situation as alarming, stating that leading PBMs wield considerable influence over the affordability and access to necessary medications for Americans. This consolidation also raises potential conflicts of interest, as vertically integrated PBMs may favor their affiliated businesses, thereby disadvantaging independent pharmacies and inflating drug costs.
FTC Chair Lina M. Khan noted that these findings indicate that these middlemen are “overcharging patients for cancer drugs,” resulting in excess revenue beyond $1 billion.