Pharmacy-benefit managers (PBMs) are reportedly directing patients towards more costly medications and restricting the locations from which they can obtain them, as indicated by a recent report from the House Committee on Oversight and Accountability.
The report, which was obtained by the Wall Street Journal, is the result of a 32-month investigation by the committee in advance of a hearing featuring executives from the largest PBMs in the country.
PBMs serve as third-party administrators of prescription drug plans for health insurers, negotiating prices with pharmaceutical companies to determine what health plans will pay for medications. They also establish out-of-pocket expenses for patients.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—collectively manage about 80% of the country’s prescriptions.
Findings from the committee’s report suggest that PBMs have developed preferred drug lists that highlight higher-priced brand-name drugs, pushing out more affordable options. One example cited in the report involves emails from Cigna staff that discouraged the use of cheaper alternatives to Humira, an arthritis treatment that cost $90,000 annually, despite the existence of at least one biosimilar available for half that price.
Additionally, the report highlighted that Express Scripts informed patients they would incur higher costs when filling prescriptions at local pharmacies compared to acquiring a three-month supply from their affiliated mail-order service, ultimately restricting patient choice in pharmacy selections.
Earlier this month, the U.S. Federal Trade Commission released a report echoing these concerns, noting that the largest six PBMs now manage nearly 95% of prescriptions filled across the nation due to rising vertical integration and concentration.
The FTC’s findings are alarming. The agency noted that leading PBMs wield substantial power over American consumers’ access to affordable prescription drugs. They suggest that the structure allows vertically integrated PBMs to favor their own associated businesses, potentially creating conflicts of interest that disadvantage independent pharmacies and inflate prescription drug prices.
FTC Chair Lina M. Khan emphasized that the analysis reveals how these intermediaries are overcharging patients for cancer medications, resulting in an additional revenue stream exceeding $1 billion for them.