A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their choices regarding where to obtain them.
The report, reviewed by the Wall Street Journal, comes after a 32-month investigation by the committee, which precedes a hearing involving executives from the nation’s largest PBMs.
PBMs act as intermediaries that manage prescription drug plans for health insurers. They negotiate prices with pharmaceutical companies and determine what patients will pay out-of-pocket for medications.
The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of all prescriptions filled in the country.
The committee’s findings indicate that PBMs have developed preferred drug lists favoring more expensive brand-name drugs over lower-priced alternatives. One example cited in the report involves communications from Cigna staff discouraging the use of more affordable options for Humira, a drug for arthritis and other autoimmune issues, which had an annual cost of $90,000 at that time. A biosimilar was available for half that amount.
Additionally, the committee discovered that Express Scripts informed patients they would pay less for a three-month supply of medication through its affiliated mail-order pharmacy than at local pharmacies, thereby limiting patients’ choices.
The U.S. Federal Trade Commission (FTC) issued a similar report earlier this month, indicating that increased consolidation and vertical integration have allowed the six largest PBMs to control nearly 95% of all prescriptions filled in the country.
These findings raise concerns over the substantial influence PBMs have over Americans’ access to affordable medications. The FTC emphasized that the vertical integration of PBMs could create conflicts of interest that hurt independent pharmacies and inflate drug costs. FTC Chair Lina M. Khan highlighted that these middlemen are overcharging patients for cancer treatments, generating over $1 billion in additional revenue.