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 access to different pharmacies. This report, seen by the Wall Street Journal, concludes a 32-month investigation ahead of an upcoming hearing with executives from the largest PBMs in the nation.
PBMs serve as third-party administrators for prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining what patients pay out of pocket. The three largest PBMs in the U.S.—Express Scripts, OptumRx (owned by UnitedHealth Group), and CVS Health’s Caremark—manage around 80% of prescriptions filled.
The committee’s findings indicate that PBMs have developed preferred drug lists that often include higher-priced brand-name medications while sidelining less expensive alternatives. The report references internal emails from Cigna discouraging the use of lower-priced substitutes for Humira, a medication for arthritis and autoimmune conditions that costs about $90,000 annually, despite the availability of a biosimilar costing significantly less.
Furthermore, the committee discovered that Express Scripts informed patients they would pay more to fill prescriptions at local pharmacies compared to ordering a three-month supply through its affiliated mail-order services, thereby limiting patient pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) published a similar report highlighting that increased vertical integration and consolidation allows the six largest PBMs to control nearly 95% of prescriptions in the country. The FTC labeled the findings as concerning, noting that leading PBMs hold considerable power over Americans’ access to affordable prescription medications. This situation creates potential conflicts of interest, where integrated PBMs may favor their affiliated businesses, adversely impacting independent pharmacies and driving up drug costs.
FTC Chair Lina M. Khan emphasized the findings reveal that these middlemen are “overcharging patients for cancer drugs,” resulting in over $1 billion in extra revenue.