A recent report from the House Committee on Oversight and Accountability reveals that pharmacy benefit managers (PBMs) are directing patients toward more expensive medications and restricting their access to various pharmacies.
The report, which was reviewed by the Wall Street Journal, comes after a 32-month investigation and precedes a hearing featuring executives from the nation’s largest PBMs. PBMs act as intermediaries between health insurers and prescription drug manufacturers, negotiating prices on behalf of health plans while also determining patients’ out-of-pocket costs.
The three largest PBMs in the U.S., Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health), are responsible for managing about 80% of prescriptions filled in the country.
According to the committee’s findings, these PBMs have established preferred drug lists that favor higher-priced brand-name medications over more affordable generic alternatives. The report highlights internal communications from Cigna suggesting that the company discouraged the use of lower-cost options for Humira, a medication for arthritis that was priced at $90,000 annually, despite the availability of a biosimilar at a significantly lower cost.
Furthermore, the committee noted that Express Scripts informed patients that they would face higher out-of-pocket expenses by filling prescriptions at their local pharmacies compared to obtaining a three-month supply through its affiliated mail-order pharmacy, thereby limiting patient pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report that stated rising vertical integration among PBMs has led the six largest firms to control nearly 95% of prescription sales in the U.S.
The FTC expressed concerns over the substantial influence these leading PBMs hold regarding Americans’ access to affordable medications. It warned that this situation creates incentives for PBMs to favor their own affiliated businesses, potentially disadvantaging independent pharmacies and contributing to increased drug prices.
FTC Chair Lina M. Khan highlighted that these findings indicate that PBMs may be overcharging patients for critical cancer therapies, resulting in additional revenue exceeding $1 billion.