Pharmacy-benefit managers (PBMs) are reportedly directing patients towards more expensive medications and restricting their choice of pharmacies, according to a recent investigation by the House Committee on Oversight and Accountability.
The findings, highlighted in a report seen by the Wall Street Journal, come ahead of a committee hearing involving executives from the nation’s largest PBMs. This investigation spanned 32 months, focusing on the significant influence these third-party administrators have over prescription drug plans offered by health insurers. PBMs negotiate prices for medications with pharmaceutical companies and determine patients’ out-of-pocket expenses.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of prescription medications filled in the country.
The committee discovered that PBMs prefer higher-priced brand name drugs over more affordable options. One example cited in the report includes internal communications from Cigna that discouraged its staff from recommending less expensive alternatives to Humira, a medication primarily used for treating arthritis, which costs about $90,000 annually, despite the existence of a biosimilar available for approximately half that amount.
Additionally, the report indicated that Express Scripts informed patients that obtaining a three-month prescription through its affiliated mail order service would be cheaper than using their local pharmacy, thus restricting patient freedom in pharmacy choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that growing consolidation among PBMs has led the six largest firms to manage nearly 95% of all prescriptions filled nationwide.
These developments raise concerns about the power wielded by major PBMs over Americans’ access to affordable medications. The FTC stated that this vertical integration could create conflicts of interest, potentially harming unaffiliated pharmacies and inflating drug prices. FTC Chair Lina M. Khan noted that these middlemen appear to be “overcharging patients for cancer drugs,” resulting in over $1 billion in additional revenue.