A recent report from the House Committee on Oversight and Accountability alleges that pharmacy-benefit managers (PBMs) are directing patients toward costlier medications while restricting their options for where to obtain them.
The findings, which were shared with the Wall Street Journal, stem from a 32-month investigation conducted by the committee, which is preparing for a hearing involving executives from the largest PBM firms in the country.
PBMs serve as intermediaries that manage prescription drug plans for health insurers. Their responsibilities include negotiating prices with pharmaceutical companies and determining the 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—handle roughly 80% of all prescriptions filled nationwide.
The committee’s report indicates that these PBMs have prioritized a selection of preferred drugs that often include higher-priced brand names rather than more affordable options. For instance, internal communications from Cigna revealed discouragement against the use of lower-cost alternatives to Humira, an arthritis treatment priced at $90,000 annually, despite the existence of a biosimilar that cost about half as much.
Moreover, the investigation found that Express Scripts informed patients that they would incur higher costs if they opted to fill prescriptions at their local pharmacies compared to getting a three-month supply through its mail-order service. This practice effectively limits patient choices regarding pharmacy options.
A similar report from the U.S. Federal Trade Commission, released earlier this month, highlighted that the consolidation and vertical integration of the six largest PBMs enable them to control nearly 95% of U.S. prescription fills. The FTC expressed concern over these developments, stating that the dominant PBMs wield significant influence over Americans’ access to affordable medications. The report noted potential conflicts of interest arising from PBMs favoring their own affiliated businesses, leading to higher drug prices and disadvantaging independent pharmacies.
FTC Chair Lina M. Khan emphasized that the revelations indicate that these middlemen are profiting from inflated charges for cancer medications, generating over $1 billion in additional revenue at patients’ expense.