According to a recent report from the House Committee on Oversight and Accountability, pharmacy benefit managers (PBMs) are pushing patients toward more expensive medications while restricting their options for where to obtain them. The report, which was reviewed by the Wall Street Journal, comes after a 32-month investigation and precedes a hearing involving executives from the largest PBMs in the nation.
PBMs act as intermediaries that manage prescription drug plans for health insurers. They negotiate prices with pharmaceutical companies and also determine out-of-pocket costs for patients. The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—control nearly 80% of all U.S. prescriptions.
The committee’s findings suggest that PBMs have developed preferred drug lists that prioritize higher-priced brand-name drugs over more affordable alternatives. For instance, the report highlights emails from Cigna staff that recommended against using cheaper alternatives for Humira, an expensive arthritis treatment that cost approximately $90,000 annually at that time, despite the availability of a biosimilar at half the price.
Additionally, the investigation revealed that Express Scripts informed patients they would incur higher costs for filling prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service. This practice limits patients’ choices regarding where to fill their prescriptions.
Earlier this month, the U.S. Federal Trade Commission released a similar report indicating that increased consolidation among PBMs has allowed the six largest firms to oversee nearly 95% of all prescriptions filled in the country. The FTC’s interim findings expressed concern over the significant influence these leading PBMs hold over patients’ access to and costs of medication. It noted that vertically integrated PBMs might prioritize their own affiliated entities, which could disadvantage independent pharmacies and drive up prescription costs.
FTC Chair Lina M. Khan pointed out that these middlemen may be overcharging patients for cancer medications, leading to additional revenues exceeding $1 billion.