A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards costlier medications and restricting their pharmacy options. This report, which was obtained by the Wall Street Journal, is the result of a 32-month investigation and comes just before a hearing featuring executives from the largest PBM companies.
PBMs act as intermediaries for health insurers, managing prescription drug plans, negotiating prices with pharmaceutical companies, and determining patients’ out-of-pocket expenses. The three largest PBMs in the United States—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—control around 80% of all prescriptions in the country.
According to the committee’s findings, PBMs are promoting preferred drug lists that favor higher-cost brand-name drugs over more affordable alternatives. For instance, the report highlights internal communications from Cigna that advised against using cheaper alternatives to Humira, an arthritis and autoimmune treatment priced at $90,000 annually, despite the availability of a biosimilar at half that cost.
Additionally, the committee noted that Express Scripts informed patients that filling prescriptions at local pharmacies would be more expensive than obtaining a three-month supply through their affiliated mail-order service. This practice effectively limits patient choice regarding pharmacy services.
A similar report from the U.S. Federal Trade Commission (FTC) released earlier this month indicated that the top six PBMs manage nearly 95% of all U.S. prescriptions. The FTC expressed concern regarding the significant power these PBMs hold over Americans’ access to affordable medications, stating that their vertical integration could lead to conflicts of interest that disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan highlighted that these middlemen are reportedly “overcharging patients for cancer drugs,” generating an extra billion dollars in revenue.