According to a recent report from the House Committee on Oversight and Accountability, pharmacy benefit managers (PBMs) are directing patients toward more costly medications while restricting their options for obtaining them.
This report, reviewed by the Wall Street Journal, is the result of a 32-month investigation conducted before an upcoming hearing featuring executives from the largest PBM companies in the country.
PBMs act as intermediaries overseeing prescription drug plans for health insurers. They negotiate payment rates with pharmaceutical firms and determine the out-of-pocket expenses for patients.
The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage approximately 80% of prescriptions in the country.
The committee’s findings revealed that these PBMs have developed preferred drug lists that often prioritize more expensive brand-name medications over less costly alternatives. The report references internal emails from Cigna indicating discouragement toward using economical alternatives to Humira, a medication for arthritis and autoimmune conditions that was priced at $90,000 annually at the time, even though a biosimilar was available for half that cost.
Additionally, the committee noted that Express Scripts informed patients they would incur higher costs at their local pharmacy compared to filling a three-month prescription through its associated mail-order pharmacy, thereby limiting patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report asserting that increased vertical integration among PBMs has allowed the six largest firms to handle nearly 95% of all prescriptions in the U.S.
The findings have raised concerns about the significant power these leading PBMs hold over Americans’ access to and affordability of prescription medications. The FTC highlighted that this situation fosters a setup where vertically integrated PBMs may favor their own affiliated companies, leading to potential conflicts of interest that can harm independent pharmacies and inflate prescription drug prices.
FTC Chair Lina M. Khan indicated that these middlemen are overcharging patients for cancer treatments, resulting in excess revenues exceeding $1 billion.