A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive prescription drugs and restricting their options for obtaining these medications.
The report, reviewed by the Wall Street Journal, comes after a 32-month investigation conducted by the committee, which is preparing for a hearing with executives from the largest PBMs in the country. These managers serve as intermediaries for prescription drug plans offered by health insurers and negotiate prices with pharmaceutical companies, determining the costs patients face.
The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control approximately 80% of prescriptions in the U.S. According to the committee’s findings, these firms have established preferred drug lists that favor more expensive brand-name medications over less costly alternatives. For instance, internal communications from Cigna indicated a discouragement of cheaper substitutes for Humira, an arthritis treatment that had an annual cost of $90,000, despite the availability of a biosimilar for half that price.
Additionally, the committee noted that Express Scripts informed patients that filling a prescription at a local pharmacy would be more costly than ordering a three-month supply via its affiliated mail-order service, effectively narrowing patients’ choices for pharmacy services.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that heightened vertical integration among PBMs has allowed the six largest firms to manage nearly 95% of all prescriptions in the United States. The FTC’s findings raise concerns about the significant influence these PBMs hold over patients’ access to affordable medications, creating conflicts of interest that may disadvantage independent pharmacies and inflate prescription costs.
FTC Chair Lina M. Khan highlighted the troubling implications of this power dynamic, emphasizing that patients are being overcharged for cancer treatments, which has generated over $1 billion in additional revenue for these middlemen.