A recent report from the House Committee on Oversight and Accountability has highlighted that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting where they can obtain them. This report, reviewed by the Wall Street Journal, comes after a 32-month investigation by the committee, which precedes a hearing involving executives from the nation’s largest PBMs.
PBMs serve as third-party administrators for prescription drug plans linked to health insurers, negotiating costs with pharmaceutical companies and determining out-of-pocket expenses for patients. The three largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—control about 80% of all prescriptions filled in the country.
The committee’s findings indicate that PBMs have established preferred drug lists that prioritize higher-priced branded medications over cheaper options. For instance, Cigna staff emails referenced in the report discouraged using more affordable alternatives to Humira, a medication for arthritis that costs around $90,000 annually, despite the existence of biosimilars available at half the price.
Additionally, the report revealed that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its mail-order service. This practice effectively restricts patient choice regarding pharmacy options.
Moreover, the U.S. Federal Trade Commission (FTC) issued a similar report this month, pointing out that the increasing consolidation among PBMs permits the six largest companies to control nearly 95% of prescriptions in the U.S. The FTC expressed concern that leading PBMs wield substantial influence over patients’ access to affordable medications, indicating that vertically integrated PBMs may favor their affiliated businesses, causing conflicts of interest and elevating drug costs.
FTC Chair Lina M. Khan noted that the findings suggest these intermediaries are “overcharging patients for cancer drugs,” contributing over $1 billion in additional revenue.