Pharmacy-benefit managers (PBMs) are allegedly directing patients towards higher-cost medications while restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability.
The report, which was reviewed by the Wall Street Journal, followed a 32-month investigation and comes in advance of a hearing featuring executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans under health insurers, negotiating prices with drug manufacturers and determining what patients pay out-of-pocket. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage around 80% of prescriptions filled in the United States.
The committee’s findings suggest that PBMs have established preferred drug lists that favor pricier brand-name medications over lower-cost alternatives. For instance, the report highlighted internal communications from Cigna that dissuaded the use of more affordable substitutes for Humira, a treatment for arthritis and other autoimmune disorders, which had a price tag of $90,000 annually, despite the availability of a similar biosimilar for half that cost.
Additionally, the committee discovered that Express Scripts informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply via their affiliated mail-order service. This practice effectively limits patients’ choice in selecting pharmacies.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that increased vertical integration among PBMs has allowed the six largest managers to dominate nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern that leading PBMs now wield considerable control over Americans’ access to affordable medications, fostering an environment where integrated PBMs might favor their own affiliated businesses, thus creating conflicts of interest that can disadvantage independent pharmacies and elevate drug costs.
FTC Chair Lina M. Khan remarked that these findings demonstrate that intermediaries are overcharging patients for cancer medications, generating more than $1 billion in additional revenue.