A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications while restricting their pharmacy options.
This report comes after a 32-month investigation, prior to a scheduled hearing involving top executives from the country’s largest PBMs. According to the Wall Street Journal, PBMs serve as third-party administrators of prescription drug plans for health insurers, negotiating drug prices with pharmaceutical companies and determining out-of-pocket costs for patients.
The three major PBMs—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—collectively manage around 80% of prescriptions in the U.S. The committee’s findings indicate that PBMs are favoring costlier brand-name drugs over less expensive alternatives in their preferred drug lists.
For instance, the report points to communications from Cigna staff advising against the use of biosimilar drugs for Humira, a medication treating arthritis and autoimmune disorders, which was priced at $90,000 annually, despite a cheaper alternative being available at half the cost.
Additionally, the committee highlighted how Express Scripts informed patients that they would incur higher costs when filling prescriptions at local pharmacies compared to using their affiliated mail-order services, thereby limiting patient pharmacy choices.
In a separate but related report, the U.S. Federal Trade Commission (FTC) noted this month that increased consolidation has allowed the six largest PBMs to control nearly 95% of U.S. filled prescriptions. The FTC’s findings raise concerns over the significant influence PBMs have on patients’ access to affordable prescription medications, suggesting that vertically integrated PBMs may prioritize their own affiliates, thus disadvantaging independent pharmacies and driving up drug costs.
FTC Chair Lina M. Khan stated that the data indicates these intermediaries may be overcharging patients for cancer therapies, generating an excess revenue of over $1 billion.