Pharmacy-benefit managers (PBMs) are allegedly pushing patients toward more costly medications and restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability.
The committee’s report, highlighted in the Wall Street Journal, is the culmination of a 32-month investigation preceding a hearing on PBMs that includes executives from the largest PBM companies.
PBMs serve as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical firms and determining out-of-pocket expenses for patients. The three largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—manage around 80% of U.S. prescriptions.
The committee discovered that PBMs often compile lists of preferred medications that prioritize more expensive branded drugs over cheaper generic options. The report refers to internal communications from Cigna that discouraged the use of lower-priced alternatives for Humira, a medication for arthritis and other autoimmune disorders that was priced at $90,000 annually, despite the availability of a biosimilar treatment for half that cost.
Additionally, the committee found that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its mail-order service, effectively limiting patient pharmacy choices.
A recent report from the U.S. Federal Trade Commission (FTC) echoed similar concerns. The FTC highlighted that due to increasing vertical integration, the six largest PBMs now control nearly 95% of all prescriptions filled in the United States.
The implications are alarming. The FTC noted that leading PBMs now wield considerable influence over Americans’ access to affordable prescription medications, resulting in a system that could favor their own associated businesses, thus disadvantaging independent pharmacies and driving up drug prices.
FTC Chair Lina M. Khan remarked that the findings indicate middlemen are overcharging patients for cancer treatments, generating over $1 billion in additional revenue.