A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications and restricting the pharmacies they can use. The findings, reported by the Wall Street Journal, come after a 32-month investigation and precede a hearing involving executives from the nation’s largest PBMs.
PBMs serve as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—control around 80% of prescriptions filled in the country.
The committee’s report highlights how these managers have curated lists of preferred medications that feature more expensive brand-name drugs while sidelining more affordable options. In one instance, Cigna’s communications were cited, which discouraged staff from recommending cheaper alternatives to Humira, an arthritis treatment priced at $90,000 annually, while a biosimilar was available for half that cost.
Additionally, the report indicated that Express Scripts informed patients they could incur higher costs by having prescriptions filled at local pharmacies rather than obtaining a three-month supply through its affiliated mail-order service, thereby limiting patient options.
Earlier this month, the U.S. Federal Trade Commission released a related report, noting that the substantial concentration of PBMs means the six largest firms manage nearly 95% of all prescriptions in the U.S. This situation, the FTC contended, raises concerns about the power PBMs wield over access to and affordability of medications for Americans. They also expressed concern over conflicts of interest that arise from the vertical integration of PBMs and their affiliated businesses, which could disadvantage independent pharmacies and inflate prescription prices.
FTC Chair Lina M. Khan stated that these middlemen are allegedly inflating costs for cancer drugs, resulting in over $1 billion in additional revenue.