A recent report from the House Committee on Oversight and Accountability alleges that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting their pharmacy options. This report, reviewed by the Wall Street Journal, emerged following a 32-month investigation prior to a hearing featuring executives from the country’s largest PBMs.
PBMs serve as intermediaries in prescription drug plans for health insurers, negotiating pricing with pharmaceutical firms and establishing out-of-pocket costs for patients. The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage about 80% of the nation’s prescriptions.
The committee’s findings indicate that PBMs are favoring high-priced brand-name medications over more affordable alternatives on their preferred drug lists. For instance, the report mentions communications from Cigna staff advising against the use of less expensive substitutes for Humira, a medication for arthritis and autoimmune conditions that costs around $90,000 annually, despite the availability of a biosimilar costing half that amount.
Additionally, the committee noted that Express Scripts informed patients they would incur higher costs if they filled prescriptions at local pharmacies compared to obtaining a three-month supply from their mail-order service, thereby limiting patients’ choices.
The U.S. Federal Trade Commission (FTC) released a similar report earlier this month, stating that heightened vertical integration has allowed the six largest PBMs to control nearly 95% of prescription fills in the U.S. The findings are alarming, as the FTC noted that dominant PBMs now wield substantial influence over Americans’ access to affordable medications. The agency highlighted concerns that these vertically integrated PBMs might favor their affiliated businesses, resulting in conflicts of interest that could harm independent pharmacies and drive up drug prices.
FTC Chair Lina M. Khan remarked that the findings indicate these intermediaries are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.