Pharmacy-benefit managers (PBMs) are reportedly directing patients towards more expensive medications and restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability.
The findings, reviewed by the Wall Street Journal, stem from a 32-month investigation by the committee, which has also slated a hearing involving executives from the country’s largest PBMs.
PBMs act as intermediaries for prescription drug plans offered by health insurers. Their role includes negotiating prices with pharmaceutical companies and determining out-of-pocket costs for patients.
The three largest PBMs—Express Scripts, OptumRx (a subsidiary of UnitedHealth Group), and Caremark (owned by CVS Health)—collectively manage about 80% of prescriptions filled in the U.S.
The committee’s report suggests that PBMs maintain lists of preferred medications that favor higher-priced brand-name drugs over less costly alternatives. For instance, emails from Cigna employees dissuaded the use of cheaper alternatives to Humira, an arthritis treatment that had an annual price tag of $90,000, despite the availability of biosimilars at half that cost.
Additionally, the report indicated that Express Scripts informed patients they would incur higher costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service. This practice, according to the committee, constrains patients’ choice of pharmacies.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report highlighting the concentration of power among the six largest PBMs, which manage nearly 95% of prescriptions in the U.S. The FTC’s findings raise concerns about PBMs’ influence on Americans’ access to affordable medications and suggest that integrated PBMs may prioritize their affiliated businesses, creating conflicts of interest that could harm independent pharmacies and escalate drug prices.
FTC Chair Lina M. Khan stated that the evidence indicates these middlemen excessively charge patients for cancer medications, generating over $1 billion in additional revenue.