Pharmacy-benefit managers (PBMs) are directing patients toward costlier medications and restricting their pharmacy options, as highlighted in a recent report from the House Committee on Oversight and Accountability.
The report, examined by the Wall Street Journal, stems from a 32-month investigation preceding a hearing featuring executives from the country’s major PBMs.
PBMs serve as third-party administrators for prescription drug plans on behalf of health insurers, negotiating prices with drug manufacturers and determining patient co-pays.
The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—handle around 80% of prescriptions in the United States.
According to the committee’s findings, these PBMs have established preferred drug lists that favor higher-priced brand-name medications over more affordable options. An example cited in the report includes internal emails from Cigna discouraging the use of cheaper alternatives to Humira, an arthritis treatment that was priced at $90,000 annually, despite at least one biosimilar being available for half that cost.
Additionally, the committee noted that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply via their affiliated mail-order service, thereby limiting patients’ pharmacy choices.
The U.S. Federal Trade Commission (FTC) released a similar report earlier this month, revealing that the six largest PBMs manage nearly 95% of prescriptions filled nationwide due to increasing consolidation and vertical integration.
The FTC’s findings raised concerns about the significant influence PBMs have on American access to affordable prescription medications. The report indicated that the operation of vertically integrated PBMs could create conflicts of interest, potentially disadvantaging independent pharmacies and driving up drug prices.
FTC Chair Lina M. Khan stated that these middlemen have been found to “overcharge patients for cancer drugs,” resulting in more than $1 billion in additional revenue for them.