Pharmacy-benefit managers (PBMs) are reportedly directing patients towards costlier medications while restricting their pharmacy choices, as highlighted in a recent report by the House Committee on Oversight and Accountability.
The report, which followed a 32-month investigation and was reviewed by the Wall Street Journal, precedes a hearing involving executives from the country’s largest PBMs. PBMs serve as intermediaries for prescription drug plans, negotiating prices between health insurers and pharmaceutical companies. They also determine out-of-pocket costs for patients.
The three largest PBMs in the United States—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—collectively manage about 80% of U.S. prescription drugs.
According to the committee’s findings, these managers have established preferred drug lists that prioritize higher-priced brand medications over more affordable options. For instance, emails from Cigna showed discouragement towards the use of cheaper alternatives to Humira, a medication with an annual cost of $90,000, despite the availability of a biosimilar at half that price.
Additionally, Express Scripts informed patients that they would incur higher costs by using a local pharmacy instead of opting for a three-month supply through its mail-order service. This practice limits the pharmacy choices available to patients.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report stating that increased vertical integration has allowed the six largest PBMs to control nearly 95% of all U.S. prescription fills.
The results are concerning, according to the FTC, which noted that leading PBMs wield considerable influence over patients’ access to and affordability of medications. This situation fosters a system where vertically integrated PBMs may favor their own affiliated companies, creating conflicts of interest that disadvantage independent pharmacies and raise drug costs.
FTC Chair Lina M. Khan remarked that these findings indicate that these intermediaries are overcharging patients for cancer treatments, resulting in excess revenue exceeding $1 billion.