Pharmacy-benefit managers (PBMs) are reportedly directing patients towards more costly medications while restricting access to alternatives, according to a recent report from the House Committee on Oversight and Accountability.
The report, which has been reviewed by the Wall Street Journal, comes after a 32-month investigation by the committee in anticipation of a hearing featuring executives from the largest PBM companies in the U.S.
PBMs serve as intermediary administrators for prescription drug plans offered by health insurers. They negotiate pricing with pharmaceutical firms and determine the out-of-pocket expenses patients face.
The trio of largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—handle roughly 80% of prescriptions across the United States.
The findings from the committee suggested that PBMs have established preferred drug lists that favor pricier brand-name medications over more affordable options. For instance, the report highlighted communications from Cigna personnel that discouraged opting for cheaper alternatives to Humira, an arthritis treatment that was priced at $90,000 per year, despite the availability of a biosimilar for about half that cost.
Additionally, the report indicated that Express Scripts informed patients they would incur higher costs filling a prescription at a local pharmacy compared to obtaining a three-month supply through its affiliated mail-order service. This practice is said to limit patient choices regarding pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, noting that the increasing consolidation among PBMs has resulted in the top six companies managing nearly 95% of all prescriptions in the U.S.
The implications of these findings are concerning. The FTC stated that “leading PBMs now wield significant influence over Americans’ access to and affordability of prescription medications.” The report also points to a system in which “vertically integrated PBMs may preferentially support their own affiliated businesses, leading to conflicts of interest that disadvantage independent pharmacies and inflate drug prices.”
FTC Chair Lina M. Khan emphasized that this data reveals that middlemen are “overcharging patients for cancer drugs,” generating an excess of over $1 billion in revenues.