A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting their options for obtaining them.
The report, referenced by the Wall Street Journal, comes after a 32-month investigation by the committee in advance of a hearing featuring executives from the largest PBMs in the country. PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses.
The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—control around 80% of prescriptions in the U.S. The committee’s findings suggest that these PBMs have established preferred drug lists that prioritize higher-priced brand-name medications over more affordable options.
One example noted in the report involves internal communications from Cigna, indicating discouragement of cheaper alternatives to Humira, a medication for arthritis and other autoimmune disorders, which costs about $90,000 annually, while at least one biosimilar was available for half that price.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to using their affiliated mail-order service. This practice was seen as limiting patient choice regarding pharmacy access.
The U.S. Federal Trade Commission’s recent report echoed similar concerns, stating that the top six PBMs now manage nearly 95% of all filled prescriptions. The FTC expressed alarm over the substantial control these PBMs have over prescription drug access and affordability for Americans, highlighting potential conflicts of interest arising from their integrated business models, which may favor affiliated pharmacies and inflate costs.
FTC Chair Lina M. Khan pointed out that these intermediaries are effectively overcharging patients for cancer medications, generating an excess revenue of more than $1 billion.