Pharmacy-benefit managers (PBMs) are directing patients toward pricier medications while restricting their access to other options, a recent report from the House Committee on Oversight and Accountability reveals.
The findings, detailed in a report accessed by the Wall Street Journal, stem from a 32-month inquiry by the committee preceding a hearing on PBMs that featured executives from the country’s leading management firms.
PBMs serve as intermediaries for prescription drug plans offered by health insurers. They negotiate pricing with pharmaceutical companies on behalf of health plans and establish out-of-pocket expenses for patients.
The report highlights that Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark, the three largest PBMs in the U.S., manage roughly 80% of all prescriptions.
According to the committee’s findings, PBMs have been prioritizing brand-name medications on their preferred drug lists, even when cheaper alternatives exist. For instance, the report references internal communications from Cigna discouraging the use of more affordable options for Humira, a medication used to treat arthritis and other autoimmune disorders, which was priced at $90,000 per year, despite a biosimilar being available for half that cost.
Additionally, the inquiry revealed that Express Scripts informed patients they would incur higher expenses at their local pharmacy compared to getting a three-month supply from its own mail-order service, thereby restricting patient choice in selecting pharmacies.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report. It indicated that ongoing consolidation has allowed the six largest PBMs to oversee nearly 95% of all filled prescriptions in the U.S.
The implications are concerning; according to the FTC, the dominant PBMs hold substantial influence over Americans’ access to affordable prescription medications, creating a framework where these vertically integrated managers may favor their affiliated businesses, leading to conflicts of interest that could disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan pointed out that the findings suggest these intermediaries are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.