A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy benefit managers (PBMs) are directing patients toward more costly medications and restricting their access to various pharmacies. This report, reviewed by the Wall Street Journal, stems from a 32-month investigation and precedes a hearing featuring executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans provided by health insurers, negotiating with pharmaceutical companies regarding drug pricing. They also determine the out-of-pocket expenses patients incur for their prescriptions. The three dominant PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—are responsible for managing about 80% of prescriptions in the country.
The committee’s findings indicate that these PBMs prioritize drug lists that favor higher-priced brand-name medications over less expensive alternatives. An example highlighted in the report involves communications from Cigna employees discouraging patients from opting for cheaper substitutes for Humira, a medication for arthritis and other autoimmune disorders, which costs around $90,000 annually. In contrast, a biosimilar version is available at approximately half that cost.
Additionally, the report notes that Express Scripts informed patients they would incur higher costs when filling prescriptions at local pharmacies, suggesting they receive a three-month supply from its mail-order service instead. This practice limits patients’ choices regarding pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that the six largest PBMs control nearly 95 percent of all prescriptions filled in the United States due to increasing vertical integration. The FTC expressed concerns about the substantial influence these PBMs hold over Americans’ access to and affordability of medications. The report also raises alarms about potential conflicts of interest in practices that favor affiliated businesses, consequently disadvantaging independent pharmacies and driving up prescription costs.
According to FTC Chair Lina M. Khan, the outcomes reveal that PBMs are significantly overcharging patients for medications, particularly cancer treatments, and generating additional revenue exceeding $1 billion in the process.