A recent report from the House Committee on Oversight and Accountability highlights concerns regarding pharmacy-benefit managers (PBMs), accusing them of steering patients toward more expensive medications while limiting their pharmacy options.
This report, which was reviewed by the Wall Street Journal, stems from a 32-month investigation by the committee prior to a hearing featuring executives from some of the largest PBMs in the country. PBMs act as third-party administrators for prescription drug plans associated with health insurers, negotiating drug prices with pharmaceutical companies and determining out-of-pocket expenses for patients.
The three largest PBMs in the United States—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—account for about 80% of all prescriptions filled in the country. The committee’s findings revealed that PBMs maintain preferred drug lists that often include higher-priced brand names over lower-cost alternatives.
For instance, the report references internal communications from Cigna discouraging the use of more affordable alternatives to Humira, a medication for arthritis and other autoimmune diseases that carried a price tag of $90,000 annually, despite the availability of a biosimilar costing half as much.
The investigation also indicated that Express Scripts informed patients they would incur higher costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service, thus limiting patient choice.
Coinciding with this report, the U.S. Federal Trade Commission (FTC) published its own findings, noting that the significant concentration of power among six major PBMs has led to them managing nearly 95% of all prescriptions in the nation. The FTC raised alarms about the considerable influence these PBMs wield over patients’ access to and affordability of prescription medications. They suggest that vertically integrated PBMs may prioritize their own affiliated businesses, ultimately disadvantaging independent pharmacies and escalating drug costs for consumers.
FTC Chair Lina M. Khan emphasized that these practices are resulting in increased charges to patients for cancer treatments, generating over $1 billion in additional revenue for the PBMs involved.