A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward costlier medications and restricting access to certain pharmacies.
The findings, shared with the Wall Street Journal, came after a 32-month investigation leading to a hearing involving executives from the major PBMs in the nation. PBMs serve as third-party administrators for prescription drug plans offered by health insurers, negotiating prices between pharmaceutical companies and health plans while determining patients’ out-of-pocket expenses.
The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—control an estimated 80% of prescriptions across the United States.
The committee’s report indicated that PBMs curate lists that favor pricier brand-name drugs instead of more affordable alternatives. For instance, the report highlighted communications from Cigna employees discouraging the use of less expensive substitutes for Humira, a medication for arthritis and autoimmune disorders, which costs around $90,000 annually, even though a biosimilar was available for half that price.
Furthermore, the report noted that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service, thereby limiting patients’ pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) published a similar report, citing that increasing vertical integration among PBMs has allowed the six largest managers to oversee nearly 95% of all prescriptions in the country.
The FTC expressed concern over the significant influence that leading PBMs wield over Americans’ access to affordable medications. The agency highlighted that this consolidation can lead to conflicts of interest, particularly when PBMs favor their own associated businesses, adversely affecting independent pharmacies and driving up drug costs. FTC Chair Lina M. Khan emphasized that these intermediaries are “overcharging patients for cancer drugs,” resulting in over $1 billion in additional revenue for them.