Pharmacy-benefit managers (PBMs) are reportedly directing patients towards pricier medications while restricting their access to alternatives, according to a recent report from the House Committee on Oversight and Accountability.
The report, which emerged after a 32-month investigation and was examined by the Wall Street Journal, coincides with an upcoming hearing on PBMs involving executives from major management firms.
PBMs serve as third-party administrators for prescription drug plans offered by health insurers. They negotiate pricing with pharmaceutical companies and also determine out-of-pocket expenses for patients.
The three leading PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—collectively handle about 80% of all prescriptions.
The committee’s findings indicate that PBMs maintain lists of preferred medications that favor higher-priced brand-name drugs over more affordable options. The report highlights instances where staff at Cigna discouraged the use of less expensive alternatives to Humira, a medication for arthritis and autoimmune conditions that costs $90,000 annually, despite the availability of a similar biosimilar at half the price.
Additionally, the investigation revealed that Express Scripts informed patients they would pay more for prescriptions filled at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service. This policy appears to limit patients’ choices regarding pharmacy selection.
Earlier this month, the Federal Trade Commission (FTC) released a report echoing these concerns, indicating that the top six PBMs dominate virtually 95% of all U.S. prescriptions.
The FTC’s findings are alarming, suggesting that prominent PBMs wield considerable influence over Americans’ access to affordable medications. The report noted potential conflicts of interest, as vertically integrated PBMs could prioritize their own affiliated businesses, jeopardizing unaffiliated pharmacies and driving up drug prices.
FTC Chair Lina M. Khan pointed out that these middlemen are significantly inflating costs for cancer medications, resulting in an additional revenue stream exceeding $1 billion for them.