A new report from the House Committee on Oversight and Accountability indicates that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications and restricting their pharmacy choices.
The report, which was shared with the Wall Street Journal, comes after a 32-month investigation by the committee, just prior to a hearing involving executives from the country’s largest PBMs.
PBMs act as third-party administrators for prescription drug plans set by health insurers and negotiate with drug manufacturers regarding costs. They also determine the out-of-pocket expenses for patients under these plans.
The largest PBMs in the U.S.—Express Scripts, OptumRx (owned by UnitedHealth Group), and Caremark (part of CVS Health)—manage around 80% of all prescriptions.
Findings from the committee reveal that these PBMs have established preferred drug lists that favor higher-priced brand name drugs in lieu of more affordable options. The report highlights instances where staff at Cigna discouraged using less expensive alternatives for medications like Humira, which was priced at $90,000 annually at that time, despite the availability of a biosimilar for half that cost.
Additionally, the committee discovered that Express Scripts advised patients they would incur higher costs by using local pharmacies instead of its own mail-order pharmacy for a three-month medication supply, effectively limiting patient choices.
This concern is echoed by a recent report from the U.S. Federal Trade Commission (FTC), which noted that an increase in vertical integration has allowed the six largest PBMs to oversee nearly 95% of all U.S. prescriptions.
The FTC expressed alarm over the substantial control these leading PBMs hold over Americans’ access to affordable prescription drugs. It highlighted potential conflicts of interest that arise from PBMs favoring their own affiliated businesses, which could disadvantage independent pharmacies and elevate drug costs. The FTC Chair, Lina M. Khan, pointed out that these middlemen have been overcharging patients for cancer medications, generating excess revenue exceeding $1 billion.