A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting their options for obtaining these drugs. This report, which was seen by the Wall Street Journal, is the result of a 32-month investigation conducted in anticipation of a hearing involving executives from the largest PBMs in the country.
PBMs act as intermediaries for health insurers, managing prescription drug plans and negotiating prices with pharmaceutical companies. They also determine out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, OptumRx (a part of UnitedHealth Group), and Caremark (owned by CVS Health)—are responsible for about 80% of all prescriptions filled in the U.S.
The committee’s findings indicate that PBMs maintain preferred drug lists that favor higher-priced brand-name medications over more affordable alternatives. For instance, the report highlights internal communications from Cigna that discouraged the use of a cheaper alternative to Humira, a drug used to treat arthritis and autoimmune conditions, which was priced at $90,000 per year, with at least one biosimilar available for half that amount.
Additionally, the committee’s investigation uncovered instances where Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to ordering a three-month supply from its mail-order facility. This tactic limited patients’ choices regarding pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that consolidation among PBMs has allowed the six largest companies to control nearly 95% of prescriptions in the United States. The FTC’s interim findings are concerning, noting that the leading PBMs hold considerable influence over American patients’ access to affordable medications. The report suggests that the integrated nature of these PBMs may promote conflicts of interest, resulting in higher costs and disadvantaging independent pharmacies.
FTC Chair Lina M. Khan emphasized that the evidence points to middlemen in the prescription drug market overcharging patients, particularly for cancer treatments, generating upwards of $1 billion in additional revenue.