Pharmacy benefit managers (PBMs) are directing patients towards more costly medications while restricting their choices of pharmacies, according to a recent report from the House Committee on Oversight and Accountability.
The report, which was examined by the Wall Street Journal, comes after a 32-month investigation into PBMs in anticipation of a hearing featuring executives from the largest management firms in the country.
PBMs serve as intermediaries administering prescription drug plans for health insurers. They negotiate drug prices with pharmaceutical companies and determine the out-of-pocket costs for patients.
The three largest PBMs in the United States—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—together manage about 80% of all prescriptions in the country.
The committee’s findings indicate that these PBMs have established preferred drug lists that prioritize higher-priced brand medications over lower-cost options. For instance, the report highlights communications from Cigna staff that discouraged patients from opting for cheaper substitutes to Humira, a drug for arthritis and other autoimmune disorders, which carries an annual cost of $90,000, even though at least one biosimilar is available at half that price.
Additionally, the committee noted that Express Scripts informed patients that filling a prescription at a local pharmacy would be more expensive than obtaining a three-month supply through its mail-order service, thereby limiting patient pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report stating that rising vertical integration among PBMs has led to the six largest firms controlling nearly 95% of prescriptions filled in the United States.
The findings raise significant concerns. The FTC noted, “Leading PBMs exert considerable power over Americans’ access to and affordability of prescription medications,” and pointed out that the vertically integrated PBMs might favor their own affiliated businesses, which creates conflicts of interest that could harm independent pharmacies and drive up drug prices.
FTC Chair Lina M. Khan remarked that these findings suggest that PBMs are “overcharging patients for cancer drugs,” which has generated more than $1 billion in additional revenue for them.