Pharmacy-benefit managers (PBMs) are directing patients toward costlier medications while restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability.
The report, which was reviewed by the Wall Street Journal, comes after a 32-month investigation by the committee in anticipation of a hearing on PBMs that will include executives from the country’s largest management firms.
PBMs function as intermediaries in managing prescription drug plans for health insurers. They negotiate prices with pharmaceutical companies on behalf of health plans and determine patients’ out-of-pocket costs. The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—handle about 80% of prescriptions in the U.S.
According to the committee’s findings, PBMs have developed preferred drug lists that prioritize higher-priced brand-name medications over more affordable options. The report highlights internal emails from Cigna staff that advised against opting for cheaper alternatives to Humira, an arthritis treatment that cost $90,000 annually, despite the presence of a biosimilar available for half that price.
Additionally, the report indicates that Express Scripts informed patients they would incur higher costs if they filled prescriptions at their local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service. This practice effectively limits patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that the growing consolidation of the six largest PBMs has enabled them to control nearly 95% of all prescriptions filled in the nation.
The findings raise serious concerns, with the FTC noting that the top PBMs significantly influence Americans’ access to and affordability of prescription medications. This situation fosters a system where PBMs might have incentives to favor their own affiliated businesses, potentially disadvantaging independent pharmacies and elevating drug costs.
FTC Chair Lina M. Khan stressed that the research indicates that these intermediaries are “overcharging patients for cancer drugs,” resulting in excess revenue of over $1 billion.