Pharmacy benefit managers (PBMs) are directing patients towards more costly medications while restricting options for where they can obtain them, as highlighted in a recent report from the House Committee on Oversight and Accountability.
The report, reviewed by the Wall Street Journal, follows a 32-month investigation by the committee in anticipation of a hearing featuring executives from the country’s leading PBMs.
PBMs serve as third-party administrators of prescription drug plans for health insurers. They negotiate with pharmaceutical companies to determine the costs that health plans will pay for medications and also establish patients’ out-of-pocket expenses.
The three largest PBMs in the United States—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—manage around 80% of prescriptions filled in the country.
According to the committee’s findings, PBMs have developed lists of preferred drugs that tend to favor higher-priced brand-name medications over more affordable alternatives. For instance, the report references emails from Cigna staff that discouraged the use of lower-cost alternatives to Humira, a treatment for arthritis and other autoimmune conditions that had an annual cost of $90,000, even though at least one biosimilar was available for about half that price.
The investigation also revealed that Express Scripts informed patients that filling a prescription at a local pharmacy would cost them more than obtaining a three-month supply from its affiliated mail-order pharmacy, thereby limiting patients’ choices of pharmacies.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that the “increasing vertical integration and concentration” allows the six largest PBMs to control nearly 95% of all prescriptions filled in the U.S.
The FTC’s findings raised concerns, revealing that “the leading PBMs now wield significant power over Americans’ access to and affordability of prescription drugs.” The report suggested a system in which “vertically integrated PBMs seem to have both the opportunity and motivation to favor their own affiliated businesses,” leading to potential conflicts of interest that might harm independent pharmacies and escalate prescription drug costs.
FTC Chair Lina M. Khan stated that these findings indicate that these middlemen are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.