Pharmacy benefit managers (PBMs) are directing patients towards more costly medications and restricting their choices regarding where to obtain them, as detailed in a recent report from the House Committee on Oversight and Accountability.
This report, which follows a 32-month investigation, precedes an upcoming hearing featuring executives from the largest PBMs in the country. The findings were reported by the Wall Street Journal.
PBMs serve as intermediary administrators of prescription drug plans for health insurers, negotiating drug prices with pharmaceutical companies and determining the out-of-pocket costs for patients. The three largest PBMs in the U.S.—Express Scripts, OptumRx (a part of UnitedHealth Group), and CVS Health’s Caremark—control around 80% of all prescriptions filled in the nation.
The committee discovered that PBMs have developed lists of preferred medications that prominently feature higher-priced brand-name drugs while sidelining more affordable alternatives. The report highlights emails from Cigna that discouraged the use of a lower-cost alternative to Humira, an arthritis treatment that came with an annual price tag of $90,000, despite the availability of a similar biosimilar at roughly half that cost.
Additionally, the committee found that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from their affiliated mail-order service, effectively limiting patient pharmacy options.
A related report from the U.S. Federal Trade Commission (FTC) released earlier this month stated that the “growing vertical integration and concentration has allowed the six largest PBMs to oversee nearly 95% of all prescriptions filled in the U.S.” The FTC expressed concern over the significant control leading PBMs yield over patients’ access and affordability regarding prescription medications. It noted that the current system favors vertically integrated PBMs, creating conflicts of interest that may disadvantage independent pharmacies and raise drug prices.
FTC Chair Lina M. Khan indicated that these middlemen are “overcharging patients for cancer drugs,” which generates excess revenue exceeding $1 billion.