A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards pricier medications and restricting their pharmacy options. The report, which was seen by the Wall Street Journal, follows a 32-month investigation ahead of a congressional hearing featuring executives from the major PBMs.
PBMs serve as intermediaries for prescription drug plans, negotiating prices with pharmaceutical companies on behalf of health insurers 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—handle about 80% of all prescriptions.
The committee’s findings indicate that PBMs maintain lists of preferred medications that often include more expensive brand-name drugs instead of lower-cost alternatives. An example highlighted in the report mentions internal communications from Cigna that advised against using less expensive options for Humira, a medication costing around $90,000 annually, while a biosimilar was available for about half that price.
Moreover, the report details claims from Express Scripts suggesting that patients would incur higher costs by using their local pharmacies compared to obtaining a three-month supply from their mail-order service. This practice reportedly restricts patient choice regarding pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report, noting that the leading six PBMs now oversee nearly 95% of all prescriptions filled in the U.S. The FTC’s interim report expressed concern over the significant control these PBMs hold over Americans’ access to affordable prescription medications, indicating that this creates conflicts of interest that could disadvantage independent pharmacies and escalate drug prices.
FTC Chair Lina M. Khan emphasized that the findings suggest PBMs are charging patients excessively for cancer treatments, generating over $1 billion in additional revenue.