Pharmacy-benefit managers (PBMs) have been found to be directing patients towards more costly medications while restricting their pharmacy options, according to a recent report by the House Committee on Oversight and Accountability.
The report, which has been reviewed by the Wall Street Journal, comes after a comprehensive 32-month investigation ahead of an upcoming hearing involving executives from the nation’s top PBMs.
PBMs are third-party administrators that manage prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket costs. The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (under CVS Health)—together manage about 80% of all prescriptions filled in the country.
The committee discovered that PBMs are promoting lists of preferred medications that favor higher-priced brand-name drugs over more affordable alternatives. In one instance, the report includes emails from staff at Cigna that advised against using less expensive options for Humira, an arthritis treatment that was priced at $90,000 annually, even though a biosimilar version was available at half that cost.
Additionally, it was revealed that Express Scripts informed patients they would incur higher costs by using their local pharmacies instead of obtaining a three-month supply from their affiliated mail-order service, which the committee argued limited patients’ pharmacy choices.
This issue has also been echoed in a recent report by the U.S. Federal Trade Commission (FTC), which found that a small number of large PBMs control nearly 95 percent of prescription fulfillment in the U.S. The FTC highlighted the concerning power these leading PBMs hold over American patients’ access to affordable prescription drugs, suggesting that their vertical integration creates conflicts of interest and may inflate drug costs.
FTC Chair Lina M. Khan noted that the findings indicate that these intermediaries are excessively charging patients for cancer medications, contributing over $1 billion in additional revenue.