A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their pharmacy options.
The report, which was reviewed by the Wall Street Journal, concludes a 32-month investigation into the practices of PBMs prior to an upcoming hearing with executives from major PBM corporations.
PBMs serve as intermediaries for managing prescription drug plans for health insurers. They negotiate prices with pharmaceutical companies and determine the out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, OptumRx (a subsidiary of UnitedHealth Group), and Caremark (part of CVS Health)—control approximately 80% of all prescriptions in the United States.
Findings from the committee indicate that PBMs have created lists of preferred medications that prioritize higher-priced name-brand drugs over more affordable alternatives. For instance, the report includes emails from Cigna employees advising against the use of lower-cost options for Humira, an arthritis treatment that at the time cost $90,000 annually, although a biosimilar was available for half that price.
Additionally, Express Scripts informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through their mail-order service, thus restricting patient choice in pharmacy selection.
Recently, the Federal Trade Commission (FTC) released a similar report expressing concerns over increasing vertical integration in the PBM sector, which now accounts for nearly 95% of all prescriptions filled in the U.S.
The FTC reported that the dominant PBMs exert considerable influence on American access to and affordability of prescription drugs, creating a system where vertically integrated PBMs may favor their subsidiaries. This situation generates conflicts of interest that can negatively affect independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan stated that these findings suggest PBMs are overcharging patients for essential medications, particularly cancer drugs, resulting in an additional profit of over $1 billion.