Pharmacy-benefit managers (PBMs) are reportedly directing patients towards pricier medications while restricting their access to other options, according to a new report from the House Committee on Oversight and Accountability.
This report follows a lengthy 32-month investigation by the committee and comes ahead of a hearing that will include executives from some of the largest PBMs in the country. PBMs serve as third-party administrators for prescription drug plans associated with health insurers, negotiating drug prices with pharmaceutical companies and determining out-of-pocket expenses for patients.
According to the report, the three largest PBMs in the United States—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—together manage about 80% of all prescriptions in the country.
Findings outlined in the report suggest that PBMs have established preferred drug lists that highlight more expensive brand-name drugs over cheaper alternatives. For instance, the report references internal communications from Cigna, which advised against cheaper alternatives for Humira, a drug used to treat arthritis and other autoimmune conditions that costs around $90,000 annually. At least one available biosimilar could be obtained for half that amount.
The report indicates that Express Scripts informed patients they would incur higher costs by filling a prescription at a local pharmacy compared to obtaining a three-month supply through its own mail-order service, thereby limiting patient choice in pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report, highlighting that increased vertical integration and consolidation have allowed the six largest PBMs to oversee nearly 95% of all prescriptions filled in the country.
These findings raise significant concerns, suggesting that leading PBMs wield considerable influence over Americans’ accessibility and affordability of prescription medications. The FTC noted that this dynamic creates a scenario where vertically integrated PBMs could prioritize their own affiliated entities, leading to conflicts of interest that disadvantage independent pharmacies and elevate prescription drug costs.
FTC Chair Lina M. Khan remarked that the evidence indicates these intermediaries are “overcharging patients for cancer drugs,” resulting in over $1 billion in added revenue for them.