A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications and restricting their options for obtaining prescriptions. This report, seen by the Wall Street Journal, follows a 32-month investigation and precedes a hearing featuring executives from the major PBMs.
PBMs serve as middlemen for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket costs. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control approximately 80% of prescriptions filled in the United States.
The committee’s findings suggest that PBMs maintain lists of preferred medications that favor higher-cost brand-name drugs over more affordable alternatives. For instance, emails from Cigna staff discouraged the use of cheaper alternatives to Humira, an arthritis and autoimmune treatment priced at $90,000 annually, while a biosimilar was available for significantly less.
Additionally, Express Scripts allegedly informed patients that they would incur higher costs by using local pharmacies compared to obtaining a three-month supply through its mail-order service, thereby limiting patient choice.
This report echoes a recent interim analysis by the U.S. Federal Trade Commission, which noted that the six largest PBMs now manage nearly 95% of all prescriptions in the U.S. The FTC’s findings raise concerns regarding the power these PBMs hold over patients’ access to affordable medications, indicating potential conflicts of interest that favor their own affiliated enterprises while disadvantaging independent pharmacies.
FTC Chair Lina M. Khan emphasized that these middlemen are inflating costs for patients, particularly for cancer treatments, resulting in over $1 billion in additional revenue for PBMs.