A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients to more expensive medications while restricting their pharmacy choices. The Wall Street Journal obtained the report following a 32-month investigation ahead of a hearing that will involve executives from the largest PBMs in the country.
PBMs serve as intermediaries for health insurers’ prescription drug plans, negotiating prices with pharmaceutical companies and setting out-of-pocket costs for patients. The three largest PBMs in the U.S.—Express Scripts, OptumRx (owned by UnitedHealth Group), and Caremark (part of CVS Health)—handle approximately 80% of all prescriptions.
The committee found that PBMs often create preferred drug lists that prioritize higher-priced brand-name medications over lower-cost alternatives. One example highlighted was an email from Cigna staff discouraging the use of cheaper options for Humira, a medication for arthritis and other autoimmune conditions that cost $90,000 annually, despite at least one biosimilar being available for half that price.
Additionally, the report noted that Express Scripts informed patients they would pay more for prescriptions at local pharmacies than if they ordered a three-month supply from its affiliated mail-order service, thus limiting their options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that increasing vertical integration has allowed the six largest PBMs to handle nearly 95% of prescriptions in the U.S. The findings raise serious concerns about the power PBMs hold over Americans’ access to affordable medications. The FTC noted that this dynamic creates a system where vertically integrated PBMs have incentives to favor their businesses, which can disadvantage independent pharmacies and increase drug costs.
FTC Chair Lina M. Khan added that these middlemen have been “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.