Pharmacy-benefit managers (PBMs) are reportedly directing patients towards pricier medications while restricting their pharmacy options, according to a recent report by the House Committee on Oversight and Accountability.
The document, which was reviewed by the Wall Street Journal, is the result of a 32-month investigation and precedes a congressional hearing featuring executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans on behalf of health insurers. They negotiate prices with pharmaceutical companies and determine the out-of-pocket costs patients must pay.
Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark dominate the market, managing about 80% of prescriptions in the United States.
The committee’s findings revealed that PBMs have developed lists of preferred drugs that favor more expensive brand-name products over lower-priced alternatives. For instance, the report highlights internal communications from Cigna that advised against using cheaper substitutes for Humira, a treatment for arthritis and other autoimmune disorders, which was priced at $90,000 annually, even though a biosimilar was available for half that amount.
Furthermore, the committee discovered that Express Scripts informed patients that they would incur higher costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply through their affiliated mail-order service. This practice effectively limits patients’ choices regarding where they can receive their medications.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a related report, indicating that the significant vertical integration of the six largest PBMs allows them to oversee nearly 95% of all prescriptions filled in the nation.
The situation raises concerns. The FTC stated that these leading PBMs now wield considerable influence over Americans’ access to affordable medications. It also suggested that these vertically integrated PBMs have the ability and incentive to favor their own affiliated services, which could hurt independent pharmacies and lead to increased drug costs.
FTC Chair Lina M. Khan emphasized that the findings reveal that these intermediaries are “overcharging patients for cancer drugs,” with an added revenue boost exceeding $1 billion.