A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients toward higher-priced medications while restricting their options for obtaining them. This conclusions follow a thorough 32-month investigation by the committee and precede hearings involving top executives from the major PBM companies.
PBMs act as intermediaries that manage prescription drug plans for health insurers, negotiating pricing with pharmaceutical companies and determining the out-of-pocket expenses that patients must pay.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—together control around 80% of the nation’s prescriptions.
The committee’s findings indicate that these managers often favor more expensive brand-name drugs over cheaper alternatives, as reported by the Wall Street Journal. An example provided in the report includes internal communications from Cigna discouraging the prescription of less costly alternatives to Humira, a treatment for autoimmune conditions that was priced at $90,000 annually, despite the existence of a biosimilar available for much less.
Furthermore, the report highlights that Express Scripts has informed patients that filling a prescription at a local pharmacy would result in higher costs compared to obtaining a three-month supply through its mail-order service, thereby limiting patient choices regarding pharmacy selection.
Adding to concerns, the U.S. Federal Trade Commission (FTC) released a similar report earlier this month, noting that the dominance of the six largest PBMs has resulted in them managing nearly 95% of all prescriptions filled in the United States.
The FTC’s report emphasizes the troubling implications of this concentration, stating that leading PBMs now hold significant influence over Americans’ access to and affordability of prescription medications. It raises alarms about potential conflicts of interest due to vertically integrated PBMs favoring their affiliated businesses, which can hurt independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan pointed out that these intermediaries are reportedly overcharging patients for cancer medications, leading to more than $1 billion in additional revenue for the PBMs.