According to a recent report from the House Committee on Oversight and Accountability, pharmacy-benefit managers (PBMs) are directing patients towards pricier medications and restricting their pharmacy options. The findings, revealed in a report seen by the Wall Street Journal, stem from a 32-month investigation conducted by the committee ahead of a hearing involving executives from the nation’s leading PBMs.
PBMs serve as intermediaries for health insurers, managing prescription drug plans by negotiating pricing with pharmaceutical companies. They also determine patients’ out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—handle around 80% of American prescriptions.
The report indicates that PBMs have developed preferred drug lists that often favor higher-priced brand-name medications over more affordable options. An example highlighted in the report includes communications from Cigna staff discouraging the use of cheaper alternatives to Humira, a medication for arthritis and other autoimmune diseases, which at the time cost approximately $90,000 annually, whereas a biosimilar was available for about half that price.
Furthermore, the committee found that Express Scripts informed patients that filling a prescription at a local pharmacy would be more expensive than obtaining a three-month supply from its affiliated mail-order pharmacy, effectively limiting patients’ pharmacy choices.
Earlier this month, the Federal Trade Commission released a similar report, noting that increasing consolidation and vertical integration have allowed the six largest PBMs to oversee nearly 95% of prescriptions filled in the U.S. The findings raised concerns about the significant influence these leading PBMs exert on patients’ access to affordable prescription medications and highlighted potential conflicts of interest favoring their affiliated businesses.
FTC Chair Lina M. Khan emphasized that these middlemen are effectively “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue as a result.