Pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their choices for obtaining them, according to a recent report released by the House Committee on Oversight and Accountability.
The committee’s findings, reported by the Wall Street Journal, stem from a 32-month investigation preceding an upcoming hearing where executives from the country’s largest PBMs will testify.
PBMs act as intermediaries that manage prescription drug plans for health insurance providers. They negotiate pricing with pharmaceutical companies to determine costs for health plans, while also establishing out-of-pocket expenses for patients.
The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of all prescriptions filled in the country.
The report highlights that PBMs maintain lists of preferred medications that often favor higher-priced brand-name drugs over more affordable options. For instance, it references emails from Cigna staff discouraging the use of economical alternatives to Humira, a medication for arthritis and other autoimmune disorders that was priced around $90,000 annually, despite the availability of biosimilars at approximately half that cost.
Additionally, Express Scripts reportedly informed patients that filling a prescription at a local pharmacy would be more costly than receiving a three-month supply via its affiliated mail-order service, thus restricting patient choice in selecting pharmacies.
Earlier this month, the U.S. Federal Trade Commission (FTC) also released a report echoing similar concerns. It noted that increasing consolidation and vertical integration has allowed the six largest PBMs to manage nearly 95% of all prescriptions in the U.S.
The FTC’s findings are alarming, as it emphasized that the primary PBMs hold substantial influence over Americans’ access to and affordability of prescription drugs. The situation fosters an environment where vertically integrated PBMs may have incentives to prioritize their own affiliated businesses, leading to conflicts of interest that could harm independent pharmacies and elevate drug costs for consumers.
FTC Chair Lina M. Khan highlighted that these middlemen are reportedly “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.