Pharmacy-benefit managers (PBMs) are directing patients towards more costly medications and restricting their options for obtaining them, according to a recent report from the House Committee on Oversight and Accountability.
The report, which was reviewed by the Wall Street Journal, was the result of a 32-month investigation ahead of a hearing featuring executives from the country’s largest PBMs.
PBMs serve as third-party administrators for prescription drug plans offered by health insurers. They negotiate prices with pharmaceutical companies and establish the out-of-pocket costs for patients.
The three largest PBMs in the U.S.—Express Scripts, OptumRx (a subsidiary of UnitedHealth Group), and Caremark (owned by CVS Health)—account for approximately 80% of prescriptions filled in the country.
The committee’s findings indicate that PBMs are promoting preferred medication lists that prioritize higher-priced brand-name drugs over more affordable alternatives. An example highlighted in the report includes emails from Cigna that dissuaded staff from recommending cheaper substitutes for Humira, a drug for arthritis and other autoimmune disorders that cost around $90,000 annually, despite the availability of at least one biosimilar at half that price.
Furthermore, the committee found that Express Scripts informed patients that they would incur higher expenses if they filled prescriptions at local pharmacies, as opposed to obtaining a three-month supply from its affiliated mail-order service. This practice limits patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, noting that “increasing vertical integration and concentration” has allowed the six largest PBMs to control nearly 95% of all prescriptions filled in the nation.
The FTC expressed concern over these developments, stating that “the leading PBMs now exercise significant power over Americans’ ability to access and afford their prescription drugs.” The report further indicated that this system may create conflicts of interest, disadvantaging non-affiliated pharmacies and raising drug costs for consumers.
FTC Chair Lina M. Khan emphasized the findings, noting that these PBMs are “overcharging patients for cancer drugs,” resulting in an additional revenue exceeding $1 billion for these intermediaries.