Pharmacy-benefit managers (PBMs) are reportedly directing patients towards more costly medications and restricting their choices of pharmacies, as indicated by a recent report from the House Committee on Oversight and Accountability.
This report, reviewed by the Wall Street Journal, comes after a 32-month investigation preceding a hearing involving executives from the nation’s largest PBMs.
PBMs serve as third-party administrators for prescription drug plans offered by health insurers. They negotiate pricing with pharmaceutical companies on behalf of health plans and determine the out-of-pocket expenses for patients.
The three largest PBMs in the U.S. – Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health – control roughly 80% of prescriptions filled in the country.
The committee’s findings suggest that PBMs have curated preferred drug lists that favor higher-priced brand-name medications over more affordable options. For instance, emails from Cigna employees discouraged patients from opting for less expensive alternatives to Humira, a medication for arthritis and autoimmune diseases that was priced at $90,000 annually when cheaper biosimilars were available at half that cost.
Additionally, the committee discovered that Express Scripts informed patients that they would incur higher costs if filling prescriptions at local pharmacies compared to the three-month supply available through its affiliated mail-order service, which effectively limited patient pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report stating that the six largest PBMs manage nearly 95% of all prescriptions in the United States due to increasing vertical integration and concentration.
These findings indicate worrying trends, with the FTC highlighting that leading PBMs have significant control over Americans’ access to affordable prescription medications. This framework can lead to vertically integrated PBMs promoting their own affiliated businesses, resulting in conflicts of interest that disadvantage independent pharmacies and elevate drug costs.
FTC Chair Lina M. Khan emphasized that the investigation revealed that these intermediaries are “overcharging patients for cancer drugs,” generating extra revenue exceeding $1 billion.