A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their pharmacy options.
The report, which was reviewed by the Wall Street Journal, is the product of a 32-month investigation and precedes a hearing involving leaders from the country’s top PBMs. PBMs serve as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with drug manufacturers and establishing out-of-pocket costs for patients.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—collectively manage about 80% of prescriptions nationwide. According to the committee’s findings, these PBMs have prioritized more expensive brand-name drugs on their preferred medication lists, often at the expense of more affordable alternatives.
The report highlighted instances such as internal communications from Cigna that discouraged the use of less expensive substitutes for Humira, a medication for arthritis and several autoimmune conditions, which was priced at $90,000 annually, despite the availability of a biosimilar at half that cost.
The committee further indicated that Express Scripts informed patients they would incur higher costs if they filled prescriptions at local pharmacies compared to acquiring a three-month supply through its affiliated mail-order service, thereby limiting patient choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that the leading six PBMs oversee nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern over the significant influence these PBMs wield over patients’ access to affordable medications, noting potential conflicts of interest that could harm unaffiliated pharmacies and raise drug prices.
According to FTC Chair Lina M. Khan, these findings underscore that PBMs may be overcharging patients for cancer medications, resulting in excess revenues exceeding $1 billion.