Pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting their choice of pharmacies, according to a recent report from the House Committee on Oversight and Accountability.
The report, which followed a 32-month investigation and was reviewed by the Wall Street Journal, comes ahead of a hearing involving executives from the nation’s major PBMs.
PBMs serve as third-party administrators for prescription drug plans, acting on behalf of health insurers. They negotiate prices with pharmaceutical companies and determine the out-of-pocket costs that patients incur. The three largest PBMs in the U.S. — Express Scripts, OptumRx (a UnitedHealth Group subsidiary), and CVS Health’s Caremark — handle about 80% of prescriptions written in the country.
Findings from the committee indicate that PBMs maintain lists of preferred drugs that favor higher-priced brand-name medications over more affordable alternatives. For instance, the report references internal communications from Cigna that discouraged the prescription of cheaper options to Humira, a medication for arthritis and other autoimmune disorders that had a yearly cost of $90,000, even though a biosimilar was available for roughly half that price.
Additionally, the committee discovered that Express Scripts informed patients they would pay more at local pharmacies than for a three-month supply obtained through its affiliated mail-order service, restricting patient options regarding pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) published a related report, indicating that increased vertical integration among PBMs has enabled the six largest managers to oversee nearly 95% of all prescriptions filled in the U.S.
The implications of these findings are concerning. The FTC noted that leading PBMs wield considerable influence over American access to affordable medications, and the situation appears to allow vertically integrated PBMs to favor their own operations, raising conflicts of interest that could disadvantage non-affiliated pharmacies and escalate drug costs.
FTC Chair Lina M. Khan highlighted that these middlemen could be “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.