A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their pharmacy options.
The findings, which were highlighted by the Wall Street Journal, followed a 32-month investigation by the committee in anticipation of a hearing featuring leaders from the country’s top PBMs.
PBMs act as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket costs. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage approximately 80% of the nation’s prescriptions.
The committee’s report indicates that these managers create preferred drug lists that favor higher-priced brand-name drugs over more affordable alternatives. For instance, emails from Cigna employees discouraged the use of lower-priced alternatives to Humira, an expensive treatment for arthritis and autoimmune conditions, which was priced at $90,000 annually, despite the availability of a biosimilar for about half that cost.
Additionally, Express Scripts reportedly informed patients that filling a prescription at their local pharmacy would be more expensive than obtaining a three-month supply through their affiliated mail-order service, effectively limiting patient choice in pharmacy selection.
The Federal Trade Commission (FTC) echoed these concerns in a recent report, noting that the six largest PBMs control nearly 95% of all prescriptions filled in the U.S. The FTC warned that these PBMs wield considerable influence over patients’ access to affordable medications. It suggested that the business practices of vertically integrated PBMs could create conflicts of interest, disadvantaging independent pharmacies while driving up drug costs.
FTC Chair Lina M. Khan emphasized that these middlemen are “overcharging patients for cancer drugs,” generating an additional $1 billion in revenue.