Pharmacy benefit managers (PBMs) are directing patients towards more costly medications and restricting their access to pharmacies, according to a recent report from the House Committee on Oversight and Accountability.
The report, which followed a 32-month investigation, is particularly relevant as a hearing involving executives from the largest PBMs in the country is set to take place. PBMs act as intermediaries for prescription drug plans and negotiate prices between pharmaceutical companies and health plans, also determining out-of-pocket costs for patients.
The three largest PBMs in the U.S. — Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (a CVS Health company) — collectively manage around 80% of U.S. prescriptions.
The committee’s findings indicate that PBMs have developed lists of preferred drugs that favor higher-priced brand-name options over cheaper alternatives. For instance, emails from Cigna staff are cited in the report, which discouraged the usage of less expensive options for Humira, a drug used to treat arthritis and other autoimmune conditions, which at the time cost $90,000 annually. A biosimilar was available for about half that price.
Furthermore, the report highlighted that Express Scripts informed patients they could save money by opting for a three-month supply through its affiliated mail-order service rather than filling prescriptions at local pharmacies, thereby limiting patient choice.
A related report from the U.S. Federal Trade Commission (FTC) released earlier this month echoed similar concerns, stating that the six largest PBMs now manage nearly 95% of all prescriptions in the United States due to increasing vertical integration.
The FTC’s findings raised alarms about the significant influence these PBMs hold over patients’ access to affordable medications. It also pointed out that the vertically integrated structure allows PBMs to favor their own affiliated businesses, posing conflicts of interest that may disadvantage independent pharmacies and contribute to rising drug costs.
FTC Chair Lina M. Khan noted that the evidence suggests that these middlemen are “overcharging patients for cancer drugs,” leading to an estimated revenue increase of over $1 billion for the PBMs.