Pharmacy benefit managers (PBMs) are directing patients towards pricier medications and restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability.
The report, which has been reviewed by the Wall Street Journal, stems from a 32-month investigation by the committee in anticipation of a hearing involving representatives from the country’s largest PBMs.
PBMs serve as intermediaries who oversee prescription drug plans for health insurers, negotiating prices with pharmaceutical firms and determining patient out-of-pocket costs. The three largest PBMs in the U.S. — Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark — are responsible for managing around 80% of prescriptions filled in the country.
The committee’s findings indicate that PBMs have created preferred drug lists that favor more expensive brand-name medications over less costly alternatives. For instance, the report highlights internal communications from Cigna discouraging the use of lower-cost alternatives to Humira, an arthritis treatment priced at around $90,000 annually, despite the existence of a biosimilar option available for half that cost.
Additionally, the report revealed that Express Scripts informed patients they would incur greater expenses by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its mail-order services. This practice restricts patient freedom regarding where they can fill their prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that the six largest PBMs manage nearly 95% of filled prescriptions in the United States due to increasing vertical integration and market concentration.
The FTC’s findings are concerning, stating that leading PBMs wield considerable control over Americans’ access to affordable prescriptions. The report suggests that vertically integrated PBMs may prioritize their own businesses, leading to conflicts of interest that disadvantage independent pharmacies and drive up drug costs.
FTC Chair Lina M. Khan emphasized that these middlemen are substantially inflating costs for patients, particularly for cancer medications, generating over $1 billion in additional revenue.