A recent report from the House Committee on Oversight and Accountability accuses pharmacy-benefit managers (PBMs) of guiding patients towards higher-priced medications while restricting their options for obtaining these drugs.
The report, reviewed by the Wall Street Journal, is the outcome of a 32-month investigation and precedes a hearing that will involve executives from the country’s largest PBMs. PBMs serve as intermediaries between health insurers and pharmaceutical companies, negotiating drug prices and determining patient out-of-pocket costs.
The three largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—control nearly 80% of the nation’s prescription drug market.
According to the committee’s findings, PBMs have developed lists of preferred medications that prominently feature more expensive brand-name drugs in lieu of cheaper generic options. The report highlights instances where staff at Cigna advised against the use of lower-cost alternatives to Humira, a drug that treats arthritis and other autoimmune diseases and has an annual cost of $90,000, despite the availability of at least one biosimilar priced at half that amount.
Additionally, the report indicates that Express Scripts informed patients they would incur higher costs if they filled prescriptions at local pharmacies compared to ordering a three-month supply from its affiliated mail-order service, thereby restricting patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that the six largest PBMs manage nearly 95% of all prescriptions in the United States due to increasing vertical integration and concentration in the industry.
The FTC expressed concern over the significant influence PBMs have over access to affordable medications. Chair Lina M. Khan criticized the practices of these middlemen, stating they are “overcharging patients for cancer drugs,” which generates over $1 billion in additional revenue for them.