Pharmacy benefit managers (PBMs) have been accused of pushing patients towards pricier medications and restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability.
The report, reviewed by the Wall Street Journal, comes after a 32-month investigation preceding a committee hearing featuring executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating drug prices with pharmaceutical companies and determining patients’ out-of-pocket costs.
The three largest PBMs in the U.S. — Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark — collectively handle around 80% of prescriptions in the country.
The committee’s findings indicated that PBMs have established preferred drug lists dominated by high-cost brand-name medications instead of more affordable alternatives. For instance, the report highlighted emails from Cigna staff urging against the use of lower-cost substitutes for Humira, a drug for arthritis and other autoimmune diseases that was priced at $90,000 annually, despite the availability of a biosimilar for half that price.
Additionally, the committee discovered 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 associated mail-order service, thus limiting patients’ pharmacy choices.
Earlier this month, the Federal Trade Commission (FTC) released a similar report, stating that the growing vertical integration and concentration among PBMs allows the six largest firms to control nearly 95% of all U.S. prescriptions filled.
The FTC expressed concern over these developments, noting that leading PBMs hold significant influence over patients’ access to affordable medications. “Vertically integrated PBMs appear to have the ability and incentive to favor their affiliated businesses, which can harm independent pharmacies and elevate drug prices,” the commission stated.
FTC Chair Lina M. Khan emphasized that the findings reveal these middlemen are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.