A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their pharmacy options. This report, examined by the Wall Street Journal, follows a 32-month investigation as the committee prepares for a hearing involving executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—handle approximately 80% of prescriptions in the U.S.
The investigation highlighted that these PBMs are favoring lists of preferred drugs that mainly consist of costlier brand-name medications rather than more affordable alternatives. For instance, emails cited in the report from Cigna staff suggested avoiding cheaper substitutes for Humira, a medication for arthritis and autoimmune conditions priced at $90,000 annually, while a biosimilar option was available for about half that cost.
The committee also noted that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, effectively limiting patient choice in pharmacy selection.
The findings resonate with a recent report from the U.S. Federal Trade Commission (FTC), which stated that increased consolidation among PBMs has allowed the six largest firms to control nearly 95% of all U.S. prescriptions. The FTC highlighted concerns over the significant influence PBMs have on Americans’ access to affordable medications, suggesting that their self-interest may disadvantage independent pharmacies and elevate drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen are overcharging patients for cancer medications, resulting in additional revenues surpassing $1 billion.