A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are pushing patients towards more costly medications while restricting their options for obtaining them.
This report was seen by the Wall Street Journal and stems from a thorough 32-month investigation ahead of a hearing featuring executives from major PBMs in the country. PBMs serve as intermediaries for prescription drug plans provided by health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket expenses.
The three leading PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—manage around 80% of prescriptions nationwide.
The committee’s findings indicate that PBMs often maintain lists of preferred medications that lean towards higher-priced brand-name drugs instead of cheaper alternatives. An example highlighted in the report involves emails from Cigna staff discouraging the use of a less expensive alternative to Humira, a treatment for autoimmune conditions that had a yearly cost of $90,000 at the time, despite the existence of a biosimilar costing half as much.
Furthermore, the report points out that Express Scripts informed patients that 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 has restricted patient choices concerning pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that heightened vertical integration among PBMs has allowed the six largest managers to oversee nearly 95 percent of all prescriptions filled in the United States.
These findings raised alarms, with the FTC stating that leading PBMs wield significant power over Americans’ access to affordable prescription medications. This situation fosters a landscape where integrated PBMs may favor their own businesses, leading to conflicts of interest that disadvantage non-affiliated pharmacies and inflate costs for prescription drugs.
FTC Chair Lina M. Khan emphasized that these middlemen are “overcharging patients for cancer drugs,” contributing to an additional revenue intake exceeding $1 billion.