Pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their access to pharmacy options, according to a new report released by the House Committee on Oversight and Accountability.
The report follows a 32-month investigation preceding a hearing on PBMs which included testimonies from executives of the largest PBM companies in the country.
PBMs act as intermediaries for prescription drug plans sponsored by health insurers. They negotiate prices with pharmaceutical companies and also determine the out-of-pocket expenses that patients incur.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage around 80% of prescriptions filled in the country.
According to the committee’s report, PBMs are developing lists of preferred medications that prioritize higher-cost brand-name drugs over less expensive alternatives. For instance, internal communications from Cigna reveal discouragement of cheaper substitutes for Humira, a treatment for arthritis and other autoimmune diseases, which costs roughly $90,000 annually. At least one biosimilar alternative exists for about half that cost.
Additionally, Express Scripts reportedly informed patients that filling a prescription at a local pharmacy would result in higher costs compared to obtaining a three-month supply from their affiliated mail-order pharmacy. This practice restricts patients’ choices regarding pharmacy services.
Earlier this month, the U.S. Federal Trade Commission (FTC) published a related report, stating that the six largest PBMs now manage nearly 95% of all prescriptions filled in the United States due to increasing vertical integration and concentration.
The concerns outlined in the reports are alarming. The FTC noted that leading PBMs significantly influence Americans’ access to and affordability of prescription drugs. This vertical integration creates a situation where PBMs may favor their own affiliated businesses, leading to conflicts of interest that disadvantage independent pharmacies and hike prescription costs.
FTC Chair Lina M. Khan indicated that these findings reveal how middlemen are “overcharging patients for cancer drugs,” yielding them an additional revenue exceeding $1 billion.