Pharmacy benefit managers (PBMs) are directing patients towards more costly medications while restricting their options, according to a recent report from the House Committee on Oversight and Accountability.
The report, reviewed by the Wall Street Journal, is the culmination of a 32-month investigation by the committee in anticipation of a hearing featuring executives from major PBMs in the country.
PBMs serve as third-party administrators for prescription drug plans tied to health insurers, negotiating with pharmaceutical companies on the prices health plans pay for drugs. They also determine the out-of-pocket expenses patients face.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of prescriptions filled.
Findings from the committee’s report suggest that PBMs establish preferred drug lists that favor higher-priced brand-name medications over more affordable options. For instance, the report references emails from Cigna staff that discouraged considering less expensive alternatives to Humira, an arthritis treatment costing $90,000 annually, despite a biosimilar being available at nearly half the price.
The committee discovered that Express Scripts informed patients that they would incur higher costs when filling prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, which constrained patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a related report highlighting that increased vertical integration among PBMs has enabled the largest six PBMs to manage nearly 95% of all U.S. prescriptions.
These findings raise concerns. The FTC indicated that leading PBMs wield substantial influence over Americans’ access to affordable prescription drugs, contributing to a system where “vertically integrated PBMs appear to have the ability and incentive to prefer their own affiliated businesses,” potentially disadvantaging independent pharmacies and driving up drug prices.
FTC Chair Lina M. Khan pointed out that the investigation revealed these intermediaries are “overcharging patients for cancer drugs,” leading to excess revenues exceeding $1 billion.