A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while limiting their pharmacy options.
The report, shared with the Wall Street Journal, is the result of a 32-month investigation by the committee, which anticipates a hearing featuring executives from the largest PBMs in the country. PBMs act as intermediaries for health insurers, negotiating drug prices with pharmaceutical companies and determining the out-of-pocket costs that patients must pay.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—handle around 80% of all prescriptions.
According to the committee’s findings, PBMs have established lists of preferred medications that often include higher-priced brand-name drugs instead of more affordable alternatives. For example, the report highlights internal communications from Cigna that discouraged the use of cheaper options for Humira, a medication for arthritis and other autoimmune diseases, which had an annual cost of $90,000 at the time. A biosimilar was available for around half that price.
The investigation also unveiled practices where Express Scripts informed patients that they would incur higher costs by purchasing prescriptions from their local pharmacies than by obtaining a three-month supply through its associated mail-order service. This approach restricts patients’ choices regarding where to fill their prescriptions.
Additionally, a report released earlier this month by the U.S. Federal Trade Commission indicated a similar trend, stating that heightened vertical integration and consolidation among PBMs allow the six largest firms to manage nearly 95% of all U.S. prescriptions.
These findings raise significant concerns. The FTC noted that dominant PBMs hold considerable influence over Americans’ access to and affordability of prescription medications. This situation fosters an environment where vertically integrated PBMs may prioritize their own affiliated services, thereby creating conflicts of interest detrimental to independent pharmacies and contributing to rising drug costs.
FTC Chair Lina M. Khan emphasized that these middlemen are reportedly overcharging patients for cancer medications, resulting in an additional revenue exceeding $1 billion.