Pharmacy-benefit managers (PBMs) are reportedly directing patients towards more expensive medications while restricting their access to alternatives, according to a new report from the House Committee on Oversight and Accountability.
The findings, which emerged from a 32-month investigation by the committee prior to a hearing involving executives from the leading PBMs, were detailed in a report reviewed by the Wall Street Journal. PBMs function as third-party administrators for prescription drug plans offered by health insurers, negotiating drug prices with pharmaceutical companies and determining patients’ out-of-pocket expenses.
The top three PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and Caremark under CVS Health—collectively manage around 80% of all prescriptions in the country.
The committee’s report indicates that these PBMs have established preferred drug lists that often favor higher-priced brand-name medications over more affordable options. For instance, it references emails from Cigna that advised against using cheaper alternatives to Humira, an arthritis treatment that cost around $90,000 annually at the time, despite the availability of a biosimilar for half that cost.
Additionally, findings revealed that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliate mail-order service. This practice reportedly limits patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that growing vertical integration among PBMs has led to the six largest firms controlling nearly 95% of all prescriptions in the U.S.
The data raises significant concerns, with the FTC stating that the dominant PBMs hold considerable influence over Americans’ access to affordable prescription drugs. The situation fosters a conflict of interest, potentially favoring PBMs’ own affiliated businesses and disadvantaging independent pharmacies while driving up drug costs.
FTC Chair Lina M. Khan noted that these findings suggest that PBMs are “overcharging patients for cancer drugs,” resulting in an excess revenue of over $1 billion for these middlemen.