A new report from the House Committee on Oversight and Accountability highlights that pharmacy-benefit managers (PBMs) are guiding patients toward more expensive medications while restricting their pharmacy options. The report, obtained by the Wall Street Journal, stems from a 32-month investigation and is set to inform an upcoming hearing featuring executives from the country’s largest PBMs.
PBMs act as intermediaries for health insurers managing prescription drug plans. They negotiate prices with pharmaceutical companies and determine the out-of-pocket costs for patients. Notably, Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health control about 80% of prescriptions in the U.S.
The committee’s findings reveal that PBMs often promote higher-cost brand-name medications over affordable alternatives. One example cited in the report involves communications from Cigna discouraging the use of cheaper substitutes for Humira, an expensive treatment for arthritis and other autoimmune conditions, which was priced at $90,000 annually at that time. In contrast, at least one biosimilar was available for around half that cost.
Additionally, the committee reported that Express Scripts informed patients they would incur higher expenses by filling prescriptions at their local pharmacies instead of obtaining a three-month supply through its affiliated mail-order service, which restricted patient choice.
This month, the U.S. Federal Trade Commission (FTC) released a similar report noting that the six largest PBMs now manage nearly 95% of all prescriptions in the country due to growing vertical integration and market concentration.
The FTC expressed concern over the significant influence these leading PBMs have on Americans’ access to affordable medications. The report suggests that vertically integrated PBMs may favor their own affiliated businesses, leading to conflicts of interest that disadvantage independent pharmacies and inflate drug costs. FTC Chair Lina M. Khan stated the findings indicate that these middlemen are overcharging patients for cancer treatments, generating more than $1 billion in additional revenue.