Pharmacy benefit managers (PBMs) are directing patients toward pricier medications while restricting their options for obtaining them, according to a recent report from the House Committee on Oversight and Accountability.
This report, which has been highlighted by the Wall Street Journal, comes after a 32-month investigation conducted by the committee, coinciding with a hearing featuring executives from the leading PBMs in the country.
PBMs act as intermediaries between health insurers and prescription drug plans. They negotiate pricing with pharmaceutical firms and determine 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—control around 80% of the nation’s prescriptions.
The committee’s findings indicate that PBMs often curate lists of preferred medications that favor higher-priced name-brand drugs over more affordable alternatives. For instance, emails uncovered in the report from Cigna staff discouraged patients from opting for cheaper alternatives to Humira, a treatment for arthritis and autoimmune conditions that has an annual cost of $90,000, despite at least one biosimilar available for half that amount.
Additionally, Express Scripts reportedly informed patients that filling prescriptions at local pharmacies would result in greater costs compared to obtaining a three-month supply from their affiliated mail-order service. This practice effectively restricts patient choice regarding pharmacies.
In a related earlier report, the U.S. Federal Trade Commission (FTC) highlighted similar concerns about PBMs, noting that increased consolidation has allowed the top six PBMs to manage nearly 95% of all prescriptions filled in the country.
The findings raise significant concerns, with the FTC stating that leading PBMs hold substantial influence over Americans’ access to affordable prescription medications. This scenario fosters a situation where “vertically integrated PBMs seemingly have the ability and incentive to favor their own affiliated businesses,” which can disadvantage independent pharmacies and drive up drug prices.
FTC Chair Lina M. Khan emphasized that the evidence reveals how these intermediaries are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.