A recent report from the House Committee on Oversight and Accountability indicates that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting their pharmacy options. This findings follow a 32-month investigation ahead of a hearing involving executives from the largest PBMs in the nation.
PBMs act as intermediaries for prescription drug plans, negotiating prices with pharmaceutical companies and determining the out-of-pocket costs for patients. The three largest PBMs in the U.S. – Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health) – collectively handle around 80% of the nation’s prescriptions.
The committee’s investigation revealed that PBMs prefer higher-priced brand-name drugs over cheaper alternatives. For instance, Cigna staff communications referenced within the report discouraged the use of lower-cost substitutes for Humira, a medication for arthritis and autoimmune conditions, which had an annual cost of $90,000 despite the availability of a biosimilar at half the price.
Further findings indicated that Express Scripts told patients they would incur higher costs if they filled prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service, thereby restricting patient choice.
In a related report, the U.S. Federal Trade Commission noted that increased vertical integration has allowed the six largest PBMs to oversee nearly 95% of all prescriptions in the U.S. The FTC expressed concern about the extensive control PBMs hold over patients’ access to affordable medications and highlighted conflicts of interest that may arise from PBMs favoring their affiliated businesses.
FTC Chair Lina M. Khan stated that these practices could lead to higher costs for patients, particularly for cancer drugs, resulting in over $1 billion in additional revenue for the PBMs involved.