A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications and restricting their choices of pharmacies. The findings, shared with the Wall Street Journal, emerged from a 32-month investigation conducted in anticipation of a hearing featuring executives from the nation’s largest PBMs.
PBMs serve as intermediaries for prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—collectively manage about 80% of prescriptions in the U.S.
The committee’s report indicated that PBMs are promoting higher-priced brand-name drugs over lower-cost alternatives. Emails from Cigna staff highlighted efforts to discourage the use of more affordable options to Humira, a treatment for arthritis and autoimmune disorders priced at $90,000 annually, despite the availability of a biosimilar at half that cost.
Additionally, the investigation revealed that Express Scripts informed patients they would incur higher costs by using local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service, thereby limiting patient pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that increasing consolidation in the PBM field has led to the six largest managers controlling nearly 95% of U.S. prescriptions. The FTC expressed concerns, noting that leading PBMs hold significant influence over drug accessibility and affordability for Americans. Their findings suggest that vertically integrated PBMs may favor their own businesses, leading to conflicts of interest that harm independent pharmacies and drive up medication costs.
FTC Chair Lina M. Khan remarked that these middlemen are reportedly “overcharging patients for cancer drugs,” generating additional revenues exceeding $1 billion.