Pharmacy benefit managers (PBMs) are pushing patients towards more expensive medications while restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability.
The report, reviewed by the Wall Street Journal, stems from a 32-month investigation by the committee, which is set to conduct a hearing with executives from the largest PBMs in the nation.
PBMs serve as third-party administrators for prescription drug plans under health insurers. They negotiate prices with drug manufacturers and dictate 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—control approximately 80% of all prescriptions filled in the country.
The committee’s findings indicate that PBMs curate lists of preferred medications favoring more expensive brand-name drugs over less costly alternatives. For instance, emails from Cigna employees reportedly discouraged the use of more affordable substitutes for Humira, a medication for arthritis and autoimmune diseases, which cost $90,000 annually, despite the availability of a biosimilar for about half that price.
Additionally, Express Scripts informed patients that they would incur higher costs when filling prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service, thus limiting patient choice.
Earlier this month, the U.S. Federal Trade Commission issued a similar report, noting that the growing consolidation of the six largest PBMs enables them to manage nearly 95% of all prescriptions in the U.S. The FTC expressed concern that these dominant PBMs wield considerable influence over patients’ access to affordable medications. The report highlighted a system where vertically integrated PBMs may favor their own affiliated businesses, leading to potential conflicts of interest that can harm independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan pointed out that these middlemen are significantly overcharging patients for cancer treatments, resulting in additional profits exceeding $1 billion.