Pharmacy-benefit managers (PBMs) are being accused of directing patients toward more expensive medications and restricting their access to pharmacies, according to a recent report from the House Committee on Oversight and Accountability.
The report, detailed in the Wall Street Journal, follows a 32-month investigation and precedes an upcoming hearing that will involve executives from the country’s largest PBMs.
PBMs serve as third-party administrators for prescription drug plans offered by health insurers. Their responsibilities include negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket costs for medications.
The three largest PBMs in the U.S.—Express Scripts, OptumRx (owned by UnitedHealth Group), and Caremark (part of CVS Health)—manage about 80% of all prescriptions in the country.
The committee’s findings indicate that PBMs have created lists of preferred drugs that favor higher-priced brand-name medications over more affordable generic options. For instance, the report highlights emails from personnel at Cigna discouraging the use of less expensive alternatives to Humira, a drug for arthritis and autoimmune conditions that had an annual cost of $90,000, despite the availability of a biosimilar at half that price.
Additionally, the investigation revealed that Express Scripts informed patients that they would incur higher costs when filling prescriptions at local pharmacies compared to getting a three-month supply through its affiliated mail-order service. This practice has limited patients’ choice regarding where to obtain their medications.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report, indicating that increasing vertical integration and consolidation has allowed the six largest PBMs to oversee nearly 95% of all filled prescriptions in the United States.
These findings raise concerns. The FTC noted that the dominant PBMs now wield considerable influence over Americans’ access to and affordability of prescription medications. Their practices appear to favor their own affiliated businesses, resulting in conflicts of interest that can disadvantage independent pharmacies and elevate drug costs.
FTC Chair Lina M. Khan remarked that the findings suggest these intermediaries are “overcharging patients for cancer drugs,” generating over $1 billion in extra revenue.