A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting their access to lower-priced alternatives.
According to the report, which the Wall Street Journal obtained, a 32-month investigation led to findings about PBMs, focusing on a hearing involving executives from the largest managers in the country.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies on behalf of health plans and determining patient out-of-pocket costs. The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—control approximately 80% of prescriptions filled in the U.S.
The committee’s report highlighted that these PBMs have developed preferred drug lists that favor higher-priced brand-name drugs over more affordable alternatives. For instance, emails from Cigna employees discouraged the use of cheaper substitutes for Humira, a medication for arthritis and other autoimmune conditions that costs about $90,000 annually, while at least one biosimilar was available for roughly half that amount.
Additionally, Express Scripts was found to inform patients that filling a prescription at a local pharmacy would be more expensive than obtaining a three-month supply from their mail-order pharmacy, effectively limiting patient choice.
A parallel report published earlier this month by the U.S. Federal Trade Commission (FTC) noted that increased vertical integration has allowed the six largest PBMs to manage nearly 95% of all prescriptions in the U.S. The FTC expressed concerns about the significant power PBMs hold over Americans’ access to affordable prescription drugs, suggesting that this dynamic fosters conflicts of interest that can increase drug costs while disadvantaging independent pharmacies.
FTC Chair Lina M. Khan remarked that these findings indicate that PBMs are overcharging patients for cancer medications, generating over $1 billion in additional revenue.