A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting their access to affordable options. This report, which was shared with the Wall Street Journal, follows a 32-month investigation into the practices of these managers just before a hearing that featured executives from the major PBMs in the country.
PBMs operate as third-party administrators for prescription drug plans on behalf of health insurers, negotiating drug prices with pharmaceutical companies and determining the out-of-pocket expenses for patients. Currently, Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health manage approximately 80% of all prescriptions in the U.S.
The committee’s findings indicated that PBMs have been promoting lists of preferred drugs that favor higher-priced brand medications over cheaper alternatives. An example cited in the report involves Cigna, which discouraged the use of more affordable options for Humira, an arthritis and autoimmune treatment that had an annual cost of $90,000, despite the availability of a biosimilar for half the price.
Furthermore, the investigation highlighted that Express Scripts informed patients they would incur higher costs at local pharmacies compared to filling prescriptions through its mail-order service, thereby constraining patient choices regarding pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission released a similar report, revealing that increasing concentration among PBMs enables the six largest managers to oversee nearly 95% of all prescriptions in the U.S. This concentration of power poses serious concerns regarding patient access and affordability of medications. The FTC noted that leading PBMs significantly influence Americans’ ability to obtain and afford prescription drugs. Moreover, they pointed out that vertically integrated PBMs may have financial incentives to prioritize their own affiliated businesses, potentially harming independent pharmacies and driving up drug costs.
The chair of the FTC, Lina M. Khan, stated that these findings indicate that PBMs are overcharging patients for cancer medications, resulting in additional revenue exceeding $1 billion.