Pharmacy benefit managers (PBMs) are guiding patients towards costlier medications while restricting their options for obtaining these drugs, according to a recent report from the House Committee on Oversight and Accountability.
The report, highlighted by the Wall Street Journal, emerged from a 32-month investigation conducted by the committee in advance of a hearing featuring top executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket costs for patients. Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark oversee about 80% of U.S. prescriptions.
The committee’s findings indicate that PBMs have prioritized a list of preferred medications that favor higher-priced brand names over more affordable alternatives. For instance, internal communications from Cigna discouraged the use of less expensive alternatives to Humira, a medication for arthritis and other autoimmune conditions, which costs around $90,000 annually despite the availability of biosimilars at half the price.
Additionally, Express Scripts informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service, thereby limiting patient choices regarding pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that “growing vertical integration and concentration” has allowed the six largest PBMs to manage nearly 95% of all prescriptions filled in the U.S.
The FTC’s report expressed serious concerns, stating that leading PBMs wield substantial influence over Americans’ access to and affordability of prescription medications. The report highlighted that vertically integrated PBMs might unfairly favor their own affiliated businesses, creating conflicts of interest that could disadvantage independent pharmacies and escalate drug costs.
FTC Chair Lina M. Khan emphasized that the findings reveal how these intermediaries are “overcharging patients for cancer drugs,” generating excess revenue exceeding $1 billion.