Pharmacy-benefit managers (PBMs) are directing patients toward pricier medications while restricting access to them, according to a recent report from the House Committee on Oversight and Accountability.
The report, which was reviewed by the Wall Street Journal, comes after a 32-month investigation into PBMs prior to a hearing featuring executives from some of the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans on behalf of health insurers. They negotiate prices with pharmaceutical companies and determine the out-of-pocket expenses for patients.
The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control approximately 80% of U.S. prescriptions.
The committee’s findings reveal that PBMs have developed lists of preferred medications that favor higher-priced brand-name drugs over more affordable alternatives. For example, the report references emails from Cigna staff discouraging the use of lower-cost options for Humira, a treatment for arthritis and autoimmune conditions, which was priced at $90,000 annually, despite having a biosimilar available for about half that price.
Additionally, Express Scripts reportedly informed patients that they would pay more for prescriptions filled at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order pharmacy. This approach has restricted patients’ freedom in choosing their pharmacies.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that “increasing vertical integration and concentration” has allowed the six largest PBMs to manage nearly 95% of all prescriptions filled across the United States.
These findings raise concerns. The FTC noted that “leading PBMs exercise significant power over Americans’ access to and affordability of prescription medications,” creating a landscape where vertically integrated PBMs may favor their own affiliated businesses, resulting in conflicts of interest that disadvantage independent pharmacies and inflate drug costs.
FTC Chair Lina M. Khan highlighted that these middlemen are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.