Pharmacy-benefit managers (PBMs) are directing patients towards pricier medications while restricting their options for obtaining these drugs, as revealed in a new report from the House Committee on Oversight and Accountability.
This report, which followed a 32-month investigation by the committee, comes ahead of a hearing featuring executives from some of the country’s largest PBMs.
PBMs serve as third-party administrators for prescription drug plans offered by health insurers, negotiating with pharmaceutical firms on pricing for medications. They also determine patients’ out-of-pocket costs.
The three largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—together manage roughly 80% of all prescriptions.
Findings from the committee suggest that PBMs have established preferred drug lists that favor higher-priced brand-name medications over more affordable alternatives. The report specifically mentions communications from Cigna employees that urged against the use of lower-cost options for Humira, a treatment for arthritis and other autoimmune conditions, then priced at $90,000 annually, despite at least one biosimilar available for half that cost.
Additionally, the committee discovered that Express Scripts informed patients that they could incur higher costs by filling their prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service. This practice restricts patients’ choices regarding which pharmacy to utilize.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, highlighting that increased vertical integration and concentration have allowed the six largest PBMs to control nearly 95% of all prescriptions in the country.
The findings are concerning. The FTC emphasized that major PBMs currently wield substantial influence over Americans’ access to and affordability of prescription medications. Furthermore, it creates a situation where these vertically integrated PBMs may prefer their own affiliated entities, leading to conflicts of interest that can disadvantage independent pharmacies and drive up drug costs.
FTC Chair Lina M. Khan criticized the middlemen for potentially overcharging patients for cancer treatments, resulting in excess revenue exceeding $1 billion.