Pharmacy-benefit managers (PBMs) are reportedly guiding patients toward more costly medications while restricting their pharmacy options, as outlined in a recent report from the House Committee on Oversight and Accountability.
The report, which followed a 32-month investigation and was reviewed by the Wall Street Journal, comes prior to a hearing featuring executives from the leading PBMs in the country.
PBMs function as third-party administrators for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket costs. The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—handle around 80% of U.S. prescriptions.
According to the committee’s findings, PBMs are promoting lists of preferred medications that highlight pricier brand-name drugs instead of their more affordable counterparts. The report references emails from Cigna staff discouraging the use of cheaper alternatives to Humira, a treatment for arthritis and other autoimmune disorders, which had an annual cost of $90,000. In contrast, at least one biosimilar was available for approximately half that price.
Additionally, the committee discovered that Express Scripts informed patients they would incur greater expenses by filling prescriptions at local pharmacies compared to ordering a three-month supply from its affiliated mail-order service. This practice effectively restricts patients’ choices regarding their pharmacy.
The U.S. Federal Trade Commission (FTC) recently published a similar analysis, indicating that the six largest PBMs now manage nearly 95 percent of all prescriptions filled in the U.S. The FTC’s interim report expressed concerns over the considerable authority these leading PBMs wield in influencing Americans’ access to affordable medications.
The findings are alarming, with the FTC noting that the current PBM practices result in significant conflicts of interest that could negatively impact independent pharmacies and inflate prescription costs. FTC Chair Lina M. Khan highlighted that these middlemen are reportedly overcharging patients for cancer medications, leading to additional revenues exceeding $1 billion.