Pharmacy benefit managers (PBMs) are directing patients towards more expensive medications while restricting their choices regarding where to fill prescriptions, according to a recent report from the House Committee on Oversight and Accountability.
The report, which was reviewed by the Wall Street Journal, is the result of a 32-month investigation and comes ahead of a congressional hearing featuring executives from some of the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket costs. The three leading PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—control around 80% of prescriptions filled in the U.S.
The findings of the committee highlighted that PBMs have been promoting preferred drug lists that prioritize higher-priced brand-name medications over less expensive generic options. For instance, emails from Cigna employees noted discouragement of cheaper alternatives to Humira, an expensive treatment for arthritis and other autoimmune diseases, which was priced at approximately $90,000 annually, despite the availability of a biosimilar at half that cost.
Additionally, Express Scripts reportedly informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from their associated mail-order service. This practice has restricted patients’ pharmacy choices.
The U.S. Federal Trade Commission (FTC) released a similar report earlier this month, asserting that increased vertical integration has allowed the six largest PBMs to manage nearly 95% of all prescriptions in the country. The FTC stated that these leading PBMs wield substantial influence over patients’ access to affordable medications, causing conflicts of interest as they might favor their own affiliated businesses over independent pharmacies.
FTC Chair Lina M. Khan remarked that the findings indicate that these intermediaries are overcharging patients for cancer drugs, resulting in over $1 billion in additional revenue for themselves.