Pharmacy benefit managers (PBMs) are directing patients toward pricier medications while restricting their access to certain pharmacies, according to a recent report from the House Committee on Oversight and Accountability.
The report, as noted by the Wall Street Journal, is based on a 32-month investigation conducted by the committee in anticipation of a hearing that will involve executives from leading PBMs in the country.
PBMs serve as third-party administrators of prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses.
The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of prescriptions filled in the U.S.
The committee’s findings indicate that PBMs maintain lists of preferred drugs that favor more expensive brand-name medications over more affordable alternatives. For instance, the report mentions internal communications from Cigna that encouraged avoiding cheaper substitutes for Humira, which was being sold for $90,000 annually despite the availability of a biosimilar that cost half that amount.
Additionally, the committee revealed that Express Scripts informed patients they would incur higher costs when filling prescriptions at local pharmacies compared to obtaining a three-month supply from their affiliated mail-order service. This practice effectively restricts patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that the largest six PBMs manage nearly 95% of prescriptions in the country due to increasing vertical integration and concentration within the industry.
The FTC’s findings raised concerns about the substantial influence of leading PBMs on Americans’ access to and affordability of prescription medications. The report also highlighted the potential conflicts of interest, suggesting that vertically integrated PBMs might prioritize their own affiliated businesses, disadvantaging independent pharmacies and elevating drug costs.
FTC Chair Lina M. Khan pointed out that these middlemen are allegedly “overcharging patients for cancer drugs,” generating additional revenue exceeding $1 billion.