Pharmacy benefit managers (PBMs) are allegedly directing patients toward costlier medications and restricting 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, is the result of a 32-month investigation by the committee and precedes a hearing on PBMs that will feature executives from the largest PBM firms in the nation.
PBMs serve as third-party administrators of prescription drug plans for health insurers, negotiating prices with drug manufacturers and determining out-of-pocket costs for patients.
The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—collectively manage about 80% of U.S. prescriptions.
Findings from the committee indicate that PBMs are favoring high-priced brand-name drugs over less expensive alternatives. The report includes emails from Cigna employees who recommended against using cheaper options for Humira, a medication that costs around $90,000 annually, despite the availability of a biosimilar at half that price.
Additionally, the committee discovered that Express Scripts informed patients that obtaining a three-month supply through their affiliated mail-order service would be cheaper than filling a prescription at a local pharmacy, effectively limiting patient pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, noting that increased vertical integration among PBMs has allowed the six largest entities to manage nearly 95% of all prescriptions filled in the U.S.
These developments raise concerns, as the FTC stated that leading PBMs now wield significant influence over Americans’ access to affordable prescription medications. The FTC highlighted potential conflicts of interest, as vertically integrated PBMs may prioritize their own affiliated businesses, disadvantaging independent pharmacies and increasing costs for patients.
FTC Chair Lina M. Khan commented on the findings, alleging that these intermediaries are “overcharging patients for cancer drugs,” leading to more than $1 billion in additional revenue for themselves.