A recent report by the House Committee on Oversight and Accountability highlights concerns regarding pharmacy-benefit managers (PBMs), asserting that they are directing patients towards costlier medications while restricting their pharmacy options.
The document, which was presented to the Wall Street Journal, stems from a 32-month investigation conducted by the committee prior to a scheduled hearing involving top executives from major PBMs. These managers act as intermediaries for health insurers in managing prescription drug plans, negotiating costs with pharmaceutical companies and determining patient out-of-pocket expenses.
The report reveals that the three largest PBMs—Express Scripts, OptumRx (a division of UnitedHealth Group), and Caremark (operated by CVS Health)—control around 80% of all prescriptions dispensed in the U.S. According to the findings, these PBMs have been developing formularies that prioritize higher-priced brand-name drugs over more affordable alternatives.
An example cited in the report includes internal communications from Cigna, which discouraged the use of less expensive alternatives for Humira, a medication for arthritis and autoimmune diseases, that was priced at $90,000 annually, despite the availability of a less costly biosimilar.
Additionally, the committee noted that Express Scripts informed consumers that filling a prescription at a local pharmacy would result in higher costs compared to obtaining a three-month supply from its own mail-order pharmacy, effectively limiting patient choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that increasing consolidation among PBMs has allowed the six largest companies to handle nearly 95% of U.S. prescriptions.
The FTC expressed concern over the significant influence these PBMs have on Americans’ access to affordable medications, creating conflicts of interest that may negatively impact independent pharmacies and raise drug prices. FTC Chair Lina M. Khan stated that PBMs have been overcharging patients for cancer treatments, generating excess revenue exceeding $1 billion.