Pharmacy-benefit managers (PBMs) are reportedly directing patients toward higher-priced medications and restricting access to pharmacies, according to a recent report from the House Committee on Oversight and Accountability.
In what marks McDonald’s first legal action related to the Quarter Pounder E. coli outbreak, the report, reviewed by the Wall Street Journal, is the culmination of a 32-month investigation by the committee. This comes ahead of a hearing where executives from the leading PBMs will testify.
PBMs serve as intermediaries in managing prescription drug plans for health insurers. They negotiate prices with pharmaceutical companies and also determine patients’ out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of all prescriptions dispensed.
The committee’s investigation revealed that PBMs have developed preferred drug lists that promote more expensive brand-name medications over lower-cost alternatives. For instance, an email from Cigna’s staff advised against opting for cheaper alternatives for Humira, a drug priced at $90,000 annually, while a biosimilar option was available at half that cost.
Moreover, Express Scripts reportedly informed patients that filling prescriptions at their local pharmacies would lead to higher costs compared to obtaining a three-month supply from their mail-order service. This practice has been criticized for limiting patient choices regarding pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a report echoing similar concerns. Their interim analysis noted that the rising consolidation in the market has allowed the six largest PBMs to manage nearly 95% of all prescriptions in the country.
The findings are alarming, with the FTC stating, “The leading PBMs now exercise significant power over Americans’ ability to access and afford their prescription drugs.” This situation fosters a system where vertically integrated PBMs may prioritize their own affiliated companies, leading to potential conflicts of interest and increased costs for patients.
FTC Chair Lina M. Khan highlighted that the results indicate these intermediaries are “overcharging patients for cancer drugs,” generating excess revenues exceeding $1 billion.