A new report from the House Committee on Oversight and Accountability reveals that pharmacy benefit managers (PBMs) are directing patients towards more costly medications while restricting their pharmacy options. The findings, which were reviewed by the Wall Street Journal, come after a 32-month investigation ahead of a hearing involving executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs—Express Scripts, OptumRx (owned by UnitedHealth Group), and Caremark (part of CVS Health)—account for about 80% of prescriptions filled in the United States.
The report indicates that PBMs have developed preferred drug lists that favor more expensive brand-name medications over cheaper alternatives. For instance, it references emails from Cigna that advised against using lower-cost substitutes for Humira, a medication for arthritis that costs around $90,000 annually, despite the availability of a biosimilar for half that price.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs if they filled prescriptions at local pharmacies compared to obtaining a three-month supply through their mail-order service. This practice effectively limits patient choices regarding where they can obtain medications.
A similar report was released earlier this month by the U.S. Federal Trade Commission (FTC), which stated that the six largest PBMs manage nearly 95% of all prescriptions in the U.S. The FTC noted that this concentration grants significant influence to PBMs over Americans’ access to affordable medications.
The situation raises concerns, as highlighted by the FTC, which pointed out that leading PBMs have substantial power over prescription drug accessibility and affordability. This structure may lead to conflicts of interest, particularly as vertically integrated PBMs may favor their own affiliated businesses, disadvantaging independent pharmacies and driving up drug prices.
FTC Chair Lina M. Khan emphasized that these findings suggest that these intermediaries are charging patients excessively for cancer treatments, resulting in more than $1 billion in additional revenue.