Pharmacy-benefit managers (PBMs) are reportedly directing patients toward higher-priced medications while restricting their access to these drugs, according to a recent report from the House Committee on Oversight and Accountability. This report follows a 32-month investigation in anticipation of a hearing involving executives from the country’s leading PBM companies.
PBMs serve as intermediaries in prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket expenses for patients. The three major PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of prescriptions filled in the U.S.
The committee’s findings indicate that PBMs have prioritized higher-priced brand-name drugs over less expensive alternatives in their preferred drug lists. For instance, the report highlighted communications from Cigna staff that discouraged the use of lower-cost alternatives to Humira, a medication for arthritis and autoimmune conditions that had an annual cost of $90,000, despite the availability of a biosimilar at half that price.
Additionally, the committee discovered that Express Scripts informed patients that they would incur greater costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply through their affiliated mail-order service, effectively limiting patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that the increasing consolidation among PBMs has allowed the largest six firms to manage nearly 95% of all prescriptions filled in the country. The FTC characterized these developments as alarming, stating that the leading PBMs wield significant influence over Americans’ access to affordable prescription medications. The report also noted that vertically integrated PBMs might favor their own affiliated businesses, leading to conflicts of interest that could disadvantage independent pharmacies and drive up drug costs.
FTC Chair Lina M. Khan emphasized that the findings reveal that these intermediaries are “overcharging patients for cancer drugs,” contributing to an excess of over $1 billion in additional revenue.