A recent report from the House Committee on Oversight and Accountability reveals that pharmacy benefit managers (PBMs) are directing patients toward more expensive medications and restricting their choices of pharmacies. This findings follows a lengthy 32-month investigation prior to a committee hearing featuring executives from the nation’s largest PBMs.
PBMs, who act as intermediaries for prescription drug plans for health insurers, negotiate prices with pharmaceutical companies and determine patients’ out-of-pocket costs. The three biggest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark— oversee nearly 80% of prescriptions in the country.
The committee’s findings indicate that these managers often compile lists of preferred medications that favor pricier brand-name drugs over lower-cost alternatives. For instance, the report referenced emails from Cigna that advised against using cheaper substitutes for Humira, which treats arthritis and other autoimmune disorders and was priced at $90,000 annually at that time, despite the availability of a biosimilar at half the price.
Additionally, the committee discovered cases where Express Scripts informed patients that they could end up paying more by filling their prescriptions at local pharmacies compared to receiving a three-month supply through its affiliated mail-order service. This practice has been criticized for limiting patient choice in selecting their pharmacy.
Coinciding with this report, the U.S. Federal Trade Commission also released its findings earlier in the month, stating that a growing concentration and integration among PBMs has resulted in the six largest managers controlling nearly 95% of all prescriptions in the United States.
The FTC expressed concern over the significant influence leading PBMs wield over Americans’ access to and affordability of medications, suggesting that this creates a system where integrated PBMs can prioritize their own entities, resulting in conflicts of interest. FTC Chair Lina M. Khan highlighted that these practices have led to patients being overcharged for cancer medications, generating over $1 billion in additional revenue for these middlemen.