Pharmacy-benefit managers (PBMs) are directing patients towards higher-cost medications and restricting their pharmacy choices, according to a new report from the House Committee on Oversight and Accountability.
The report, which was shared with the Wall Street Journal, comes after a 32-month investigation by the committee prior to a hearing on PBMs that featured executives from the country’s largest management firms.
PBMs are intermediaries that oversee prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket expenses. The three largest PBMs in the United States—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—control about 80% of the nation’s prescriptions.
The report highlights how PBMs have established preferred drug lists that prioritize higher-priced branded medications over more affordable options. Citing emails from Cigna staff, it mentions that the firm discouraged the use of less expensive alternatives to Humira, a treatment for arthritis and other autoimmune diseases that cost $90,000 annually, despite the availability of a biosimilar for approximately half that price.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs when filling prescriptions at their local pharmacies than if they obtained a three-month supply from the company’s mail-order pharmacy, effectively limiting patient choice in selecting their pharmacy.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, noting that increasing consolidation has allowed the six largest PBMs to manage nearly 95% of all prescriptions in the country. This concentration raises significant concerns, as the FTC highlighted that major PBMs now wield considerable influence over Americans’ access to and affordability of their medications. The report also noted that vertically integrated PBMs might favor their affiliated businesses, creating conflicts of interest that could disadvantage independent pharmacies and raise drug prices.
FTC Chair Lina M. Khan emphasized that these findings indicate that middlemen are “overcharging patients for cancer drugs,” generating additional revenue exceeding $1 billion.