A recent report from the House Committee on Oversight and Accountability has raised serious concerns about pharmacy-benefit managers (PBMs), claiming they are pushing patients towards costlier medications while restricting their choices regarding where to obtain their prescriptions.
The findings, which followed a 32-month investigation and were reported by the Wall Street Journal, precede an upcoming hearing featuring executives from the nation’s leading PBMs. PBMs act as third-party administrators for prescription drug plans, negotiating prices with pharmaceutical companies and determining patient out-of-pocket costs. Approximately 80% of U.S. prescriptions are managed by the three largest PBMs: Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark.
According to the committee’s report, these PBMs have developed preferred drug lists that favor expensive brand-name medications over more affordable alternatives. An example highlighted in the report involves Cigna employees advising against cheaper options for Humira, an arthritis treatment that could cost $90,000 annually, despite the availability of a biosimilar at half the price.
The committee also indicated that Express Scripts informed patients they would incur higher costs if they filled prescriptions at local pharmacies compared to ordering through their affiliated mail-order service, thus limiting pharmacy choices.
Earlier in the month, the U.S. Federal Trade Commission also released a similar report, noting that increased consolidation has allowed the six largest PBMs to manage nearly 95% of all prescriptions in the country. The FTC emphasized that this concentration grants significant power to PBMs over patients’ access to affordable medications. The commission warned that the current system engenders conflicts of interest, as vertically integrated PBMs tend to favor their own businesses, potentially disadvantaging independent pharmacies and driving up drug costs for consumers.
FTC Chair Lina M. Khan stated that these middlemen are reportedly overcharging patients for cancer medications, resulting in additional profits exceeding $1 billion.