A recent report from the House Committee on Oversight and Accountability highlights concerns about pharmacy-benefit managers (PBMs) directing patients towards more expensive prescription drugs while limiting their pharmacy options. This report, reviewed by the Wall Street Journal, is the result of a thorough 32-month investigation and comes ahead of a hearing featuring executives from the nation’s largest PBMs.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining the 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—control approximately 80% of the prescription market.
The committee’s findings indicate that PBMs maintain lists of preferred medications that favor higher-priced brand-name drugs over more economical alternatives. For instance, the report mentions internal communications from Cigna that discouraged the use of cost-effective substitutes for Humira, a treatment for arthritis and autoimmune conditions, which had a yearly cost of $90,000 despite the availability of a biosimilar at half that price.
Furthermore, the investigation revealed that Express Scripts informed patients they would incur higher costs if they chose to fill their prescriptions at local pharmacies instead of utilizing their affiliated mail-order services, effectively restricting patient choices.
In a related context, the U.S. Federal Trade Commission (FTC) released a report asserting that significant vertical integration has allowed the six largest PBMs to oversee nearly 95% of all prescriptions filled in the country. The FTC expressed concern about the considerable influence PBMs have over Americans’ access to affordable medications, noting that their structure creates conflicts of interest that may disadvantage independent pharmacies and lead to increased drug costs for patients.
FTC Chair Lina M. Khan stated that these findings indicate that PBMs are profiting excessively from patients needing cancer medications, generating over $1 billion in additional revenue.