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 pharmacy options. The report, which was seen by the Wall Street Journal, comes after a lengthy 32-month investigation ahead of an upcoming hearing featuring executives from the major PBM companies.
PBMs act as intermediaries for prescription drug plans managed by health insurers, negotiating prices with pharmaceutical companies on behalf of health plans. They also determine the out-of-pocket expenses for patients. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage about 80% of the country’s prescriptions.
The findings of the committee indicate that these PBMs have established preferred drug lists that favor higher-priced brand-name medications over less expensive alternatives. The report specifically mentions internal communications from Cigna that discouraged the adoption of cheaper substitutes for Humira, an arthritis treatment priced at $90,000 annually, while at least one biosimilar was available for half that cost.
Additionally, the committee noted that Express Scripts informed patients they would face higher costs at local pharmacies compared to obtaining a three-month supply via their affiliated mail-order service. This practice has been seen as limiting patient choice regarding pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission published a similar report highlighting that the six largest PBMs control nearly 95% of all prescriptions dispensed in the United States due to increasing vertical integration and concentration. The FTC expressed concern that leading PBMs wield considerable influence over patients’ ability to access and afford their medications, leading to potential conflicts of interest and inflated drug costs.
FTC Chair Lina M. Khan asserted that these findings demonstrate how PBMs are overpricing cancer treatments, generating more than $1 billion in additional profits at the expense of patients.