A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards pricier medications while restricting access to alternatives. This report comes after a 32-month investigation and precedes a hearing involving executives from the nation’s largest PBMs.
PBMs act as intermediaries for prescription drug plans under health insurers, negotiating drug prices with pharmaceutical firms and determining patient out-of-pocket expenses. The top three PBMs—Express Scripts, OptumRx (a division of UnitedHealth Group), and CVS Health’s Caremark—control about 80% of U.S. prescriptions.
The committee’s findings indicate that these PBMs have developed lists of preferred medications that favor higher-priced brand name drugs over more affordable options. An example mentioned in the report highlights internal communications from Cigna, which advised against using cheaper alternatives to Humira, a drug for arthritis and autoimmune issues, priced at $90,000 a year, despite a biosimilar being available for half that cost.
Additionally, the committee noted that Express Scripts informed patients they would incur greater costs by filling prescriptions at local pharmacies compared to ordering a three-month supply from their mail-order service, consequently limiting patients’ pharmacy choices.
The U.S. Federal Trade Commission (FTC) released a similar report earlier this month, stating that increased vertical integration and concentration have empowered the six largest PBMs to handle nearly 95% of all prescriptions in the United States. The FTC expressed concern that these leading PBMs hold significant influence over Americans’ access to and affordability of prescription medications. The report suggests that vertically integrated PBMs might favor their own related businesses, creating conflicts of interest that could hurt unaffiliated pharmacies and escalate drug prices.
FTC Chair Lina M. Khan remarked that the findings indicate these middlemen are “overcharging patients for cancer drugs,” leading to an additional $1 billion in revenue for them.