Pharmacy-benefit managers (PBMs) are reportedly leading patients toward costlier medications and restricting their access to certain pharmacies, as revealed in a recent report by the House Committee on Oversight and Accountability.
The report, which was seen by the Wall Street Journal, stems from a 32-month investigation by the committee ahead of an upcoming hearing featuring executives from the country’s largest PBMs.
PBMs serve as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies. They also determine patients’ out-of-pocket expenses.
The three largest PBMs in the U.S.—Express Scripts, OptumRx (a part of UnitedHealth Group), and Caremark (owned by CVS Health)—control around 80% of prescriptions in the country.
According to the committee’s findings, PBMs tend to favor lists of preferred medications that include higher-priced brand-name drugs instead of more affordable alternatives. One example highlighted in the report includes emails from Cigna that discouraged the use of cheaper substitutes for Humira, which had a price tag of $90,000 per year. A biosimilar treatment was available at half the cost.
The investigation also notes that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to ordering a three-month supply through its mail-order pharmacy, effectively limiting their pharmacy choices.
Additionally, the U.S. Federal Trade Commission released a similar report earlier this month, which indicated that the top six PBMs collectively manage nearly 95% of all prescriptions filled nationwide.
These developments raise concerns, as the FTC stated that the leading PBMs hold considerable influence over patients’ access to affordable medications. The report suggests that “vertically integrated PBMs may have the ability and motivation to favor their own affiliated businesses,” which could harm independent pharmacies and drive up drug prices.
FTC Chair Lina M. Khan emphasized that the findings indicate that these intermediaries are “overcharging patients for cancer drugs,” generating over $1 billion in extra revenue.