A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are driving patients towards more expensive medications and are restricting their options for obtaining these drugs.
The findings come from a 32-month investigation by the committee and were presented ahead of a hearing featuring executives from the country’s largest PBMs. The report, which was reviewed by the Wall Street Journal, highlights the role of PBMs as third-party administrators that manage prescription drug plans for health insurers. They negotiate prices with pharmaceutical companies and determine the 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 prescriptions filled in the country. According to the committee’s report, these PBMs have been known to create preferred drug lists that favor higher-priced brand-name drugs over more affordable alternatives.
For instance, emails from Cigna staff were cited in the report, indicating discouragement of cheaper options in favor of Humira, an arthritis treatment that costs around $90,000 annually, despite the availability of a biosimilar at half that price.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs if they chose to fill prescriptions at local pharmacies instead of opting for a three-month supply from its affiliated mail-order service, thereby restricting patient choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, noting that increased vertical integration among PBMs has led to the top six managing nearly 95% of all prescriptions in the U.S.
The FTC expressed concern over these findings, stating that leading PBMs hold considerable power over Americans’ access to affordable prescription drugs, thereby creating a system that can favor their affiliated businesses and lead to conflicts of interest that disadvantage independent pharmacies while inflating drug costs. FTC Chair Lina M. Khan emphasized that these middlemen are overpricing patients for cancer medications, resulting in over $1 billion in excess revenue.