Pharmacy-benefit managers (PBMs) are reportedly guiding patients towards more costly medications while restricting their options for obtaining these prescriptions, according to a recent report from the House Committee on Oversight and Accountability.
This report follows a 32-month investigation by the committee and comes ahead of a hearing that will include executives from the largest PBMs in the country, as detailed by the Wall Street Journal.
PBMs serve as intermediary administrators for prescription drug plans provided by health insurers. They negotiate pricing between pharmaceutical companies and health plans, while also determining the out-of-pocket expenses that patients face.
The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—control around 80% of the country’s prescription medications.
The committee’s findings indicate that PBMs have curated lists of preferred medications that often feature higher-priced brand-name drugs instead of more affordable alternatives. For instance, the report mentions emails from Cigna employees dissuading the use of cheaper alternatives to Humira, a medication used for arthritis and other autoimmune diseases, which was priced at $90,000 annually. At least one biosimilar drug was available for half that amount.
Additionally, the committee discovered that Express Scripts informed patients that filling a prescription at their local pharmacy would cost more compared to obtaining a three-month supply through their affiliated mail-order pharmacy. This practice appears to limit patient choices regarding pharmacy providers.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, noting that increased vertical integration within the industry has allowed the six largest PBMs to handle nearly 95% of all prescriptions filled in the U.S.
The results of the committee’s investigation are concerning. The FTC reported that the leading PBMs wield considerable influence over Americans’ access to affordable prescription drugs. This situation may lead to conflicts of interest as “vertically integrated PBMs” could potentially favor their affiliated businesses over independent pharmacies, resulting in higher drug costs.
FTC Chair Lina M. Khan emphasized that these findings indicate that PBMs are “overcharging patients for cancer drugs,” which has generated over $1 billion in additional revenue for these middlemen.