Pharmacy benefit managers (PBMs) have been accused of directing patients towards more expensive medications while restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability.
The report, which was reviewed by the Wall Street Journal, comes after a 32-month investigation and precedes a hearing featuring executives from the country’s largest PBMs.
PBMs serve as third-party administrators for prescription drug plans provided by health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket costs for patients.
The three largest PBMs in the United States—Express Scripts, OptumRx (operated by UnitedHealth Group), and CVS Health’s Caremark—collectively manage around 80% of all prescriptions.
Findings from the committee’s report indicated that PBMs maintain lists of preferred drugs that prioritize higher-priced branded medications over more affordable alternatives. For instance, the report highlights Cigna emails discouraging the use of cheaper options for Humira, a medication for arthritis and other autoimmune conditions, which currently costs around $90,000 annually, despite the availability of a biosimilar at half that price.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs by filling prescriptions at their local pharmacies compared to receiving a three-month supply through its affiliated mail-order service. This practice limits patients’ freedom to choose their preferred pharmacists.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that increasing vertical integration among PBMs has allowed the six largest firms to control nearly 95% of all prescriptions filled in the country.
The findings raised concerns, with the FTC stating, “The leading PBMs now exercise significant power over Americans’ ability to access and afford their prescription drugs.” This system may lead to conflicts of interest, where vertically integrated PBMs prefer their affiliated businesses, thereby disadvantaging independent pharmacies and raising drug costs.
FTC Chair Lina M. Khan noted that these middlemen are “overcharging patients for cancer drugs,” resulting in more than $1 billion in additional revenue for PBMs.