A recent report from the House Committee on Oversight and Accountability highlights concerns regarding pharmacy-benefit managers (PBMs), alleging that they are directing patients towards more expensive medications and restricting their pharmacy options.
The findings, reported by the Wall Street Journal, come after a 32-month investigation ahead of a hearing involving executives from the largest PBMs in the country. PBMs serve as intermediaries for health insurers, negotiating drug prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—control around 80% of U.S. prescription transactions.
The committee’s investigation discovered that these managers often compile lists of preferred drugs, favoring higher-priced brand-name options over more affordable alternatives. An instance highlighted in the report involved Cigna employees who discouraged the use of lower-cost substitutes for Humira, an arthritis medication costing $90,000 annually, despite the existence of a biosimilar priced at half that amount.
Additionally, it was reported that Express Scripts informed patients they would incur higher costs if they filled prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service. This practice reportedly restricts patients’ choices regarding pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that increasing consolidation and vertical integration among PBMs allows six major players to manage nearly 95% of all U.S. prescriptions. The FTC expressed concern about the considerable influence PBMs have over the affordability and accessibility of prescription medications for Americans. The report suggested that this structure creates potential conflicts of interest, favoring affiliated businesses and raising drug costs, particularly for cancer treatments, which it claims has resulted in over $1 billion in excess charges to patients.
FTC Chair Lina M. Khan emphasized the implications of the findings, pointing out that these middlemen are contributing to inflated prices for critical medications.