Pharmacy-benefit managers (PBMs) are reportedly directing patients towards pricier medications while restricting their choices of pharmacies, as detailed in a recent report by the House Committee on Oversight and Accountability.
The findings of the report, which followed a thorough 32-month investigation, coincided with a committee hearing featuring executives from the largest PBMs in the nation.
PBMs act as intermediaries for prescription drug plans on behalf of health insurers, negotiating drug prices with pharmaceutical companies and determining the out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—control nearly 80% of all prescriptions filled in the U.S.
The committee’s report revealed that PBMs have implemented lists of preferred medications that predominantly include high-cost brand names rather than more affordable options. One notable example highlighted was Cigna employees discouraging the use of less expensive alternatives to Humira, an arthritis treatment that was priced at $90,000 annually, despite the availability of a biosimilar for about half that price.
Additionally, the report indicated that Express Scripts informed patients they would incur higher costs at their local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service, thereby restricting patient pharmacy choices.
A similar finding was issued by the U.S. Federal Trade Commission (FTC) in an interim report, which noted that increased consolidation and vertical integration have allowed the six biggest PBMs to manage approximately 95% of U.S. prescriptions.
The implications of these findings are concerning. The FTC stated that the predominant PBMs hold substantial sway over Americans’ access to and affordability of prescription medications. It warned that the system allows vertically integrated PBMs to potentially favor their own affiliated operations, leading to conflicts of interest that could harm independent pharmacies and raise drug costs. FTC Chair Lina M. Khan emphasized that these middlemen are reportedly inflating costs for cancer drugs, resulting in over $1 billion in additional revenue.