Pharmacy-benefit managers (PBMs) are directing patients towards pricier medications and restricting their pharmacy options, according to a new report from the House Committee on Oversight and Accountability.
The committee’s report, reviewed by the Wall Street Journal, comes after a 32-month investigation and precedes a hearing involving executives from the largest PBMs in the country. PBMs act as intermediaries for prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses.
The three leading PBMs – Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health – manage about 80% of prescriptions in the United States. The report reveals that these managers have curated preferred drug lists that prioritize higher-priced brand-name drugs over more affordable alternatives.
An example included in the report highlights internal communications from Cigna staff, which advised against opting for more affordable alternatives to Humira, a drug for arthritis and autoimmune conditions that costs about $90,000 annually, despite the availability of a biosimilar at half that price.
Additionally, the committee found that Express Scripts advised patients they would incur higher costs if they obtained prescriptions from local pharmacies rather than its own mail-order service. This practice restricts patients’ choices regarding their pharmacy providers.
Earlier this month, the U.S. Federal Trade Commission released a similar report indicating that due to increasing vertical integration and consolidation, the six largest PBMs control nearly 95 percent of all prescriptions filled in the United States. The FTC expressed concern about the significant influence these PBMs have on patients’ access to affordable medications, noting potential conflicts of interest that could disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan remarked that the findings indicate that these intermediaries are overcharging patients for cancer treatments, resulting in over $1 billion in additional profits for them.