Pharmacy-benefit managers (PBMs) are reportedly directing patients toward more costly medications while restricting their pharmacy options, according to a new report released by the House Committee on Oversight and Accountability.
The document, which was reviewed by the Wall Street Journal, comes after a 32-month investigation by the committee and ahead of a hearing featuring executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans provided by health insurers, negotiating prices with pharmaceutical companies and establishing out-of-pocket costs for patients. The top three PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage nearly 80% of all prescriptions.
The committee’s findings indicate that these managers have created lists of preferred medications that favor higher-priced brand-name drugs over more affordable alternatives. For instance, the report highlights emails from Cigna staff discouraging the use of cheaper substitutes for Humira, an arthritis treatment priced at approximately $90,000 annually, while noting that at least one biosimilar was available for half that cost.
Additionally, the report states that Express Scripts informed patients they would incur higher expenses by filling prescriptions at local pharmacies compared to obtaining a three-month supply through their affiliated mail-order pharmacy. This practice is seen as limiting patient choice regarding pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission released a similar report, stating that increasing vertical integration has allowed the six largest PBMs to oversee nearly 95% of all prescriptions filled nationwide.
The findings raise serious concerns, as the FTC noted, “The leading PBMs now exercise significant power over Americans’ ability to access and afford their prescription drugs.” The report warns of a system where vertically integrated PBMs may favor their own affiliated businesses, resulting in conflicts of interest that can harm non-affiliated pharmacies and escalate prescription drug costs.
FTC Chair Lina M. Khan emphasized that these middlemen are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.