Pharmacy-benefit managers (PBMs) are reportedly guiding patients towards more costly medications while restricting access to various pharmacies, as indicated by a recent report from the House Committee on Oversight and Accountability.
This report, reviewed by the Wall Street Journal, comes after a 32-month investigation conducted by the committee in anticipation of a hearing featuring executives from the largest PBMs in the nation.
PBMs serve as third-party administrators for prescription drug plans affiliated with health insurers, negotiating prices with pharmaceutical companies and setting out-of-pocket costs for patients. The three largest PBMs in the U.S. — Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health — oversee roughly 80% of the nation’s prescriptions.
According to the committee’s findings, these PBMs have compiled lists of preferred drugs that prominently feature higher-priced brand-name medications over more affordable options. The report references internal emails from Cigna that advised against using less expensive substitutes for Humira, a drug prescribed for arthritis and other autoimmune conditions, which cost around $90,000 per year, despite the availability of a biosimilar priced at half that amount.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs if filling their prescriptions at local pharmacies as compared to obtaining a three-month supply from its own mail-order pharmacy. This practice limits patients’ choices regarding where to fill their prescriptions.
Earlier this month, the U.S. Federal Trade Commission released a similar report, noting that heightened vertical integration among PBMs has enabled the six largest managers to oversee nearly 95% of all prescriptions dispensed in the U.S. The FTC highlighted concerns over the significant influence these leading PBMs hold over patients’ access to affordable medications, indicating potential conflicts of interest that could negatively impact unaffiliated pharmacies and inflate drug prices.
FTC Chair Lina M. Khan remarked that the investigation reveals how these intermediaries are often overcharging patients for vital medications, including cancer treatments, contributing additional revenues exceeding $1 billion.