Pharmacy-benefit managers (PBMs) are reportedly directing patients toward more costly medications while restricting their options for obtaining these drugs, according to a recent report from the House Committee on Oversight and Accountability.
The report, which followed a 32-month investigation, was shared with the Wall Street Journal ahead of an upcoming hearing involving executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating with pharmaceutical companies regarding drug prices and determining patients’ out-of-pocket expenses.
The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—manage about 80% of all prescriptions in the country.
Findings from the committee’s report indicated that PBMs have created preferred drug lists that favor higher-priced brand-name medications over cheaper alternatives. For instance, the report highlighted emails from Cigna staff that discouraged opting for less expensive alternatives to Humira, a medication for arthritis and other autoimmune disorders that was priced at $90,000 annually, despite the availability of a biosimilar for about half that cost.
Additionally, the committee found instances where 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, thereby limiting patients’ pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) published a report echoing similar concerns, stating that increased vertical integration in the pharmacy sector has allowed the six largest PBMs to manage nearly 95% of U.S. prescriptions.
The implications of these findings are alarming. According to the FTC, “the leading PBMs now exercise significant power over Americans’ ability to access and afford their prescription drugs.” This situation contributes to a framework where these vertically integrated PBMs have incentives to favor their own affiliated businesses, which could harm independent pharmacies and escalate drug prices.
FTC Chair Lina M. Khan highlighted that these findings suggest that PBMs are “overcharging patients for cancer drugs,” resulting in additional revenue exceeding $1 billion.