Pharmacy-benefit managers (PBMs) are reportedly directing patients toward higher-priced medications while restricting their choices regarding where to obtain these drugs, according to a recent report from the House Committee on Oversight and Accountability.
The report, mentioned by the Wall Street Journal, emerged from a thorough 32-month investigation by the committee as it prepared for a hearing involving executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans for health insurers, negotiating prices between pharmaceutical companies and health plans. These managers also determine patients’ out-of-pocket expenses.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—oversee about 80% of prescriptions across the nation.
The committee’s findings revealed that these PBMs have developed lists of preferred drugs that tend to favor more expensive brand-name options over cheaper alternatives. For instance, the report highlighted emails from Cigna staff that suggested avoiding less costly alternatives to Humira, a medication for arthritis and other autoimmune diseases that was priced at $90,000 annually at that time, despite a biosimilar being available for approximately half that amount.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs filling prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order pharmacy, effectively limiting patients’ freedom to choose their pharmacy.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report. The FTC’s interim findings indicated that the increasing concentration and vertical integration have allowed the six largest PBMs to oversee nearly 95% of all prescriptions filled in the U.S.
These developments raise concerns, as noted by the FTC, which stated that the leading PBMs hold substantial influence over Americans’ access to and affordability of prescription drugs. This situation fosters an environment where “vertically integrated PBMs seem to have the capacity and motivation to favor their own affiliated businesses,” leading to potential conflicts of interest that could harm independent pharmacies and elevate prescription drug prices.
FTC Chair Lina M. Khan commented that the results indicate middlemen are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.