Pharmacy benefit managers (PBMs) are reportedly directing patients towards more costly medications while restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability.
The document, reviewed by the Wall Street Journal, stems from a thorough 32-month investigation by the committee, which was conducted in the lead-up to a hearing featuring executives from the country’s largest PBMs.
PBMs serve as intermediaries for prescription drug plans offered by health insurers. They negotiate prices with pharmaceutical companies and determine patients’ out-of-pocket costs.
The three largest PBMs in the U.S. – Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark – handle about 80% of prescription fulfillment.
The committee found that PBMs have established preferred drug lists prioritizing more expensive branded medications over cheaper alternatives. For instance, the report mentions emails from Cigna employees dissuading the use of lower-cost alternatives to Humira, an arthritis treatment priced at $90,000 annually, despite available biosimilars costing half that.
Additionally, there were findings that Express Scripts informed patients they would incur higher costs by using their local pharmacy compared to obtaining a three-month supply from an affiliated mail-order pharmacy, restricting patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report highlighting that increasing consolidation has allowed the six largest PBMs to control nearly 95% of U.S. prescriptions.
The FTC’s findings raised alarm, stating that leading PBMs wield significant influence over Americans’ access to affordable prescription drugs. This landscape fosters conditions where vertically integrated PBMs may favor their own businesses, creating conflicts of interest and driving up drug prices for consumers.
FTC Chair Lina M. Khan indicated that these middlemen are “overcharging patients for cancer drugs,” contributing over $1 billion to their revenue.