A new report from the House Committee on Oversight and Accountability reveals that pharmacy benefit managers (PBMs) are guiding patients towards costlier medications while restricting their pharmacy options. This report, which follows a 32-month investigation ahead of a hearing involving executives from the major PBMs, highlights significant concerns regarding the industry’s practices.
PBMs serve as intermediaries managing prescription drug plans for health insurers, negotiating drug prices and determining out-of-pocket costs for patients. Express Scripts, OptumRx, and Caremark – the three largest PBMs in the U.S. – control around 80% of all prescriptions.
The committee’s findings indicate that PBMs have developed preferred drug lists that often prioritize higher-priced brand-name medications over less expensive alternatives. For instance, emails from Cigna disclosed in the report indicated discouragement against using cheaper substitutes for Humira, a drug for arthritis and autoimmune conditions, which was priced at $90,000 annually, despite the availability of a biosimilar for about half that cost.
Additionally, the report noted that Express Scripts advised patients would pay more out-of-pocket if they filled prescriptions at their local pharmacy compared to using its affiliated mail-order service, thereby restricting patient choices regarding their pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that increasing consolidation has allowed the six largest PBMs to manage nearly 95% of prescriptions in the U.S. The FTC expressed concern that dominant PBMs hold considerable influence over Americans’ access to affordable medications, creating conflicts of interest that can harm non-affiliated pharmacies and inflate drug costs.
FTC Chair Lina M. Khan emphasized that these findings suggest that PBMs are significantly overcharging patients for cancer drugs, generating over $1 billion in additional revenue.