A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their pharmacy options. This report, reviewed by the Wall Street Journal, follows a 32-month investigation by the committee ahead of 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 the out-of-pocket costs for patients. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of prescriptions.
The committee’s findings indicate that PBMs often favor higher-priced brand-name drugs over more affordable alternatives. For instance, the report includes emails from Cigna employees discouraging the use of a less expensive biosimilar for Humira, a medication for arthritis and other autoimmune disorders, which had a price tag of $90,000 annually at the time.
Additionally, the committee noted that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to purchasing a three-month supply through its mail-order service. This practice restricts patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report indicating that the top six PBMs manage nearly 95% of all prescriptions in the United States. The FTC expressed concern over the significant influence these PBMs have over Americans’ access to and affordability of prescription medications. They highlighted potential conflicts of interest where vertically integrated PBMs might favor their affiliated businesses, which could disadvantage independent pharmacies and escalate drug costs.
FTC Chair Lina M. Khan remarked that the findings indicate that these intermediaries are overcharging patients for cancer medications, generating over $1 billion in additional revenue for themselves.