Pharmacy-benefit managers (PBMs) are reportedly directing patients towards pricier medications and restricting their pharmacy options, as highlighted in a recent report by the House Committee on Oversight and Accountability.
According to the report, which was reviewed by the Wall Street Journal, a 32-month investigation preceded a hearing featuring executives from the country’s largest PBMs.
PBMs act as intermediaries in managing prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket expenses. The three largest PBMs in the United States, Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark, collectively oversee around 80% of all prescriptions.
The committee discovered that PBMs tend to favor higher-priced branded medications over more affordable alternatives. The report cites examples, such as communications from Cigna discouraging the use of cheaper substitutes for Humira, an arthritis treatment costing $90,000 annually, despite the availability of a biosimilar at half that price.
Moreover, the committee learned that Express Scripts informed patients that they would pay higher costs at their local pharmacies compared to obtaining a three-month supply through its own mail-order service, thereby restricting patient choice.
A similar report from the U.S. Federal Trade Commission (FTC) earlier this month noted that due to growing vertical integration, the six largest PBMs now manage nearly 95% of all prescriptions in the country.
The FTC’s findings raised serious concerns, as they indicated that dominant PBMs hold considerable influence over Americans’ access to affordable prescription medications. This structure reportedly fosters a system where PBMs may favor their own affiliated services, potentially disadvantaging independent pharmacies and contributing to higher drug costs.
FTC Chair Lina M. Khan emphasized that these middlemen are allegedly “overcharging patients for cancer drugs,” generating additional revenue exceeding $1 billion.