Pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their choices for acquiring these drugs, highlighted in a recent report from the House Committee on Oversight and Accountability.
This report, which emerged from a 32-month investigation, precedes a hearing featuring executives from the country’s largest PBMs. According to the Wall Street Journal, PBMs act as third-party administrators for prescription drug plans on behalf of health insurers. They are responsible for negotiating drug prices with pharmaceutical companies and determining the out-of-pocket expenses for patients.
The three major PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—regulate around 80% of prescriptions filled nationwide.
The committee’s findings indicate that PBMs have developed preferred drug lists that favor higher-priced brand-name drugs over more affordable alternatives. For instance, emails from Cigna staff discouraged physicians from prescribing lower-cost alternatives to Humira, a medication for arthritis and autoimmune conditions priced at $90,000 annually, despite the existence of a biosimilar available for half that cost.
Moreover, the committee reported that Express Scripts informed patients that they would incur higher costs by filling prescriptions at their local pharmacy compared to obtaining a three-month supply from their affiliated mail-order service. This practice limits patients’ options regarding which pharmacy they can utilize.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar assessment, noting that the increasing consolidation has allowed the six largest PBMs to control nearly 95% of all prescriptions filled in the U.S.
The results of these investigations have raised concerns. The FTC stated that these leading PBMs wield considerable influence over Americans’ access to and affordability of prescription drugs. This situation fosters a system where vertically integrated PBMs may prioritize their affiliated entities, potentially disadvantaging independent pharmacies and elevating drug prices.
FTC Chair Lina M. Khan remarked that the findings illustrate how these intermediaries are “overcharging patients for cancer drugs,” contributing an excess of $1 billion in additional revenue.