Pharmacy-benefit managers (PBMs) are reportedly directing patients towards more costly medications while restricting their options for obtaining these drugs, according to a recent report from the House Committee on Oversight and Accountability.
The findings, reviewed by the Wall Street Journal, come after a 32-month investigation and are likely to be discussed in an upcoming hearing involving executives from the nation’s leading PBMs.
PBMs serve as third-party administrators for prescription drug plans offered by health insurers. They negotiate prices with pharmaceutical companies and determine the out-of-pocket expenses that patients face. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—are responsible for managing about 80% of prescriptions filled in the country.
The committee’s report highlights that PBMs have established lists of preferred medications that often favor expensive brand-name drugs over more affordable alternatives. One instance mentioned in the report includes emails from Cigna employees recommending against the use of lower-cost options for Humira, a treatment for arthritis and other autoimmune conditions, which had a yearly cost of $90,000 at the time, despite the availability of a biosimilar at half the price.
Additionally, the investigation revealed that Express Scripts informed patients they would incur higher costs by using local pharmacies, as compared to obtaining a three-month supply from their affiliated mail-order pharmacy. This practice effectively restricts patient choice regarding pharmacy selection.
The U.S. Federal Trade Commission (FTC) released a similar report earlier this month, indicating that increasing consolidation allows the six largest PBMs to oversee nearly 95% of all prescriptions filled in the United States.
The FTC expressed concern over the implications of these findings, stating that leading PBMs wield considerable power over Americans’ access to and affordability of prescription medications. The report also pointed out that “vertically integrated PBMs” may favor their own affiliated businesses, posing conflicts of interest that disadvantage independent pharmacies and raise drug costs.
FTC Chair Lina M. Khan noted that the findings reveal how these intermediaries are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.