Pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications and restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability.
The findings of this report were based on a 32-month investigation and were prepared ahead of a hearing that included discussions with executives from the largest PBMs in the country. PBMs serve as intermediaries in managing prescription drug plans for health insurers, negotiating drug prices on behalf of health plans and determining patients’ out-of-pocket expenses.
The three largest PBMs in the United States—Express Scripts, OptumRx (owned by UnitedHealth Group), and Caremark (part of CVS Health)—handle around 80% of prescriptions in the country. The report indicates that these PBMs have compiled lists of preferred medications that favor higher-priced brand-name drugs instead of cheaper alternatives.
For instance, the report references internal communications from Cigna that dissuaded the use of less expensive options for Humira, a treatment for arthritis that costs approximately $90,000 annually, despite the existence of at least one biosimilar available for half that price.
Additionally, the committee noted that Express Scripts informed patients that they would incur higher costs by filling prescriptions at their local pharmacies compared to ordering a three-month supply from its affiliated mail-order service. This practice appears to limit patients’ choice in selecting their pharmacy.
A similar report released earlier this month by the U.S. Federal Trade Commission found that increased vertical integration among PBMs has enabled the six largest companies to manage almost 95% of all prescriptions in the U.S. The FTC expressed concern over the significant power PBMs hold over Americans’ access to affordable medications, indicating that their practices may create conflicts of interest that disadvantage independent pharmacies.
FTC Chair Lina M. Khan emphasized that these findings reveal how PBMs are overcharging patients for cancer treatments, generating over $1 billion in additional revenue in the process.