Pharmacy benefit managers (PBMs) are reportedly directing patients towards more costly medications and restricting pharmacy options, as outlined in a recent report by the House Committee on Oversight and Accountability.
The report, which was reviewed by the Wall Street Journal, is the result of a 32-month investigation by the committee and precedes an upcoming hearing featuring executives from the largest PBMs in the country.
PBMs serve as intermediaries in prescription drug plans for health insurers, negotiating pricing with pharmaceutical firms on behalf of health plans and determining patients’ out-of-pocket expenses.
The three biggest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—oversee about 80% of all prescriptions in the country.
According to the committee’s findings, these managers have composed lists of preferred medications that favor higher-priced brand-name drugs instead of more affordable alternatives. The report highlights instances, such as communications from Cigna, which discouraged prescribing lower-cost substitutes for Humira, a medication for arthritis and autoimmune disorders, that at one point cost $90,000 annually, while a biosimilar option was available for about half that price.
The investigation also revealed that Express Scripts informed patients that filling prescriptions at local pharmacies would cost them more than obtaining a three-month supply through its affiliated mail-order service, effectively limiting patient choice in pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report stating that dominant vertical integration among the top six PBMs has resulted in their management of nearly 95 percent of all prescriptions dispensed across the country.
The FTC’s findings raise alarms about the substantial influence these PBMs hold over Americans’ access to affordable prescription medications. The report cautioned that the current system allows vertically integrated PBMs to favor their own businesses, creating conflicts of interest that disadvantage independent pharmacies and inflate drug costs.
FTC Chair Lina M. Khan emphasized that the research indicates these intermediaries are “overcharging patients for cancer drugs,” generating more than $1 billion in additional revenue.