Pharmacy-benefit managers (PBMs) are allegedly directing patients towards pricier medications while restricting their options for obtaining them, according to a recent report from the House Committee on Oversight and Accountability.
The findings, discussed in the Wall Street Journal, stem from a 32-month investigation by the committee and precede a hearing involving executives from some of the largest PBMs in the U.S.
PBMs serve as intermediaries for prescription drug plans, negotiating prices with pharmaceutical companies on behalf of health insurers and determining patients’ out-of-pocket expenses. The three leading PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—together manage approximately 80% of all prescriptions in the country.
The report highlights that these PBMs have developed preferred drug lists that prioritize higher-cost brand-name medications over more affordable options. One example cited in the report includes Cigna’s correspondence, which discouraged the use of less expensive alternatives to Humira, a medication for arthritis and other autoimmune disorders that was priced at $90,000 annually at the time, despite the availability of a biosimilar costing half as much.
Moreover, the committee found 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, as noted by the committee, limits patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that “increasing vertical integration and concentration” has allowed the six largest PBMs to oversee nearly 95% of all U.S. prescriptions. The FTC’s findings raise concerns about the significant power these PBMs hold over patients’ access to and affordability of prescription drugs, creating a system where vertically integrated PBMs might favor their own businesses, disadvantaging independent pharmacies and raising drug prices.
FTC Chair Lina M. Khan criticized this practice, stating that these intermediaries are “overcharging patients for cancer drugs” and generating over $1 billion in additional revenue as a result.