Pharmacy-benefit managers (PBMs) are directing patients towards higher-cost medications and restricting access to certain pharmacies, according to a recent report from the House Committee on Oversight and Accountability.
The report, which was reviewed by the Wall Street Journal, emerged after a 32-month investigation leading up to a hearing involving executives from some of the largest PBM companies in the U.S.
PBMs serve as intermediaries for prescription drug plans under health insurance providers. They negotiate prices with pharmaceutical companies and also determine the out-of-pocket expenses patients face.
Express Scripts, OptumRx of UnitedHealth Group, and CVS Health’s Caremark are the three largest PBMs in the country, collectively managing about 80% of U.S. prescription medications.
The committee’s findings indicate that PBMs have developed preferred drug lists that prioritize high-priced brand-name drugs over more affordable alternatives. One instance cited in the report involved Cigna employees discouraging cheaper alternatives to Humira, a treatment for arthritis and autoimmune disorders that cost around $90,000 annually, despite at least one biosimilar costing half that amount.
Additionally, the committee noted that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies versus obtaining a three-month supply through their associated mail-order service, effectively limiting patient choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that the growing vertical integration among PBMs has allowed the six largest companies to control nearly 95% of all U.S. prescriptions.
These revelations are concerning, with the FTC highlighting that leading PBMs possess considerable influence over Americans’ access to and affordability of prescription medications. The report further indicates that this power may create conflicts of interest, allowing vertically integrated PBMs to favor their own businesses, which can harm unaffiliated pharmacies and inflate drug prices.
FTC Chair Lina M. Khan stated that the findings reveal that middlemen are charging patients excessively for cancer medications, generating over $1 billion in additional revenue.