Pharmacy benefit managers (PBMs) are directing patients towards pricier medications while restricting their options for obtaining them, according to a recent report from the House Committee on Oversight and Accountability.
This report, examined by the Wall Street Journal, stems from a 32-month investigation by the committee in anticipation of a hearing concerning PBMs and the executives from the country’s largest management firms.
PBMs serve as intermediaries for prescription drug plans offered by health insurers. They negotiate with pharmaceutical companies regarding the prices that health plans will pay for various medications and also determine the out-of-pocket expenses for patients.
The report highlights that Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (affiliated with CVS Health) account for nearly 80% of prescriptions filled in the United States.
Key findings reveal that PBMs often curate lists of favored medications that feature higher-priced brand names over more affordable alternatives. For instance, the report mentions communications from Cigna staff that discouraged patients from considering lower-cost options to Humira, a treatment for arthritis and other autoimmune disorders priced at $90,000 annually, despite the availability of at least one biosimilar at half that cost.
Furthermore, the committee noted instances where Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through its associated mail-order service, thereby limiting patient pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission released a similar critique, indicating that heightened vertical integration among the six largest PBMs has led them to control nearly 95% of all U.S. prescriptions.
The findings are concerning, revealing that major PBMs now wield considerable influence over Americans’ access to and affordability of prescription medications. The FTC remarked that this situation fosters a landscape where vertically integrated PBMs incentivize the favoring of their own affiliated businesses, posing conflicts of interest that can disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan emphasized that the evidence indicates these intermediaries are “overcharging patients for cancer drugs,” generating additional income exceeding $1 billion.