Pharmacy benefit managers (PBMs) are directing patients toward more costly medications while restricting their choices for obtaining them, according to a recent report from the House Committee on Oversight and Accountability.
This report, reviewed by the Wall Street Journal, follows a lengthy 32-month investigation by the committee and precedes a hearing featuring executives from the largest PBMs in the country.
PBMs act as intermediaries in prescription drug plans for health insurers, negotiating prices with pharmaceutical companies for medications. They also establish the out-of-pocket expenses that patients must pay.
The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—are responsible for managing approximately 80% of prescriptions in the U.S.
The committee’s findings indicate that these PBMs have curated lists of preferred medications that predominantly include higher-cost brand-name drugs instead of more affordable alternatives. For example, the report highlights internal communications at Cigna advising against cheaper options for Humira, an arthritis treatment with an annual cost of $90,000, while at least one biosimilar treatment was available for half that price.
Moreover, the committee discovered that Express Scripts informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service. This practice reportedly restricted patients’ pharmacy choices.
Additionally, a recent report from the U.S. Federal Trade Commission (FTC) echoed these concerns. The FTC’s interim report stated that increased consolidation in the industry has allowed the six leading PBMs to control around 95% of all filled prescriptions in the United States.
These findings are alarming, highlighting the substantial influence PBMs have over Americans’ access to and affordability of prescription medications. The FTC pointed out that this situation fosters a system where vertically integrated PBMs may favor their own businesses, leading to conflicts of interest that could harm independent pharmacies and drive up drug costs.
FTC Chair Lina M. Khan remarked that the evidence indicates these intermediaries are overcharging patients for cancer medications, resulting in excess revenues exceeding $1 billion.