A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting access to affordable options. This finding follows a 32-month investigation and comes ahead of an upcoming hearing featuring executives from some of the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans on behalf of health insurers, playing a significant role in negotiations with pharmaceutical companies regarding drug pricing. They determine patients’ out-of-pocket expenses and manage approximately 80% of prescriptions in the U.S.
The committee’s report highlights that PBMs have developed lists of preferred medications that prioritize higher-priced brand-name drugs over cheaper alternatives. It cites internal communications from Cigna that discouraged the use of lower-cost options for Humira, a medication for arthritis and other autoimmune disorders, despite a biosimilar available for half the price.
Additionally, Express Scripts informed patients that they would incur higher costs for prescriptions filled at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, thereby limiting patient pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission released a similar interim report, indicating that increasing concentration among PBMs allows the six largest operators to manage nearly 95% of all filled prescriptions nationwide. The FTC expressed concern over the substantial influence PBMs exert over patients’ access to affordable medications, noting that this could lead to conflicts of interest, particularly favoring their own affiliated businesses and potentially raising drug prices at unaffiliated pharmacies.
FTC Chair Lina M. Khan emphasized that the findings indicate that these middlemen are overcharging patients for cancer medications, generating over $1 billion in additional revenue for the PBMs.