A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards pricier medications and restricting their pharmacy options. The investigation, which lasted 32 months and was highlighted in the Wall Street Journal, precedes a hearing involving executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans under health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs—Express Scripts, OptumRx (a UnitedHealth Group company), and Caremark (part of CVS Health)—manage around 80% of prescriptions in the United States.
According to the committee’s findings, PBMs often create preferred drug lists that favor higher-priced brand-name drugs over more affordable alternatives. For instance, the report points to internal communications from Cigna that discouraged the use of cheaper alternatives to Humira, a drug for arthritis priced at approximately $90,000 annually, despite the existence of a biosimilar at half that price.
The committee also noted that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through their affiliated mail-order service, thereby limiting patient choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that increasing consolidation has allowed the six largest PBMs to control nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern over the significant power these PBMs have over prescription drug access and affordability. It warned that vertically integrated PBMs may prioritize their own affiliated enterprises, potentially harming independent pharmacies and raising drug prices.
FTC Chair Lina M. Khan emphasized that these findings illustrate how middlemen are overcharging patients for cancer drugs, generating over $1 billion in additional revenue.