Pharmacy-benefit managers (PBMs) are reportedly directing patients toward higher-priced medications and restricting their access to pharmacies, according to a recent report from the House Committee on Oversight and Accountability.
The report, which has been reviewed by the Wall Street Journal, is the result of a 32-month investigation and comes ahead of a planned hearing involving executives from major PBMs in the United States.
PBMs serve as intermediaries in prescription drug plans for health insurers, negotiating prices with drug manufacturers and determining patient out-of-pocket costs. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—handle approximately 80% of prescriptions filled in the United States.
The investigation revealed that PBMs often compile lists of preferred medications that favor more expensive brand-name drugs over cheaper alternatives. One example highlighted by the report involves emails from Cigna employees dissuading the use of cost-effective alternatives to Humira, a treatment for arthritis and other autoimmune diseases that costs around $90,000 annually, while a biosimilar option was available at just half that price.
Additionally, the committee found evidence that Express Scripts informed patients they would incur higher costs for prescriptions filled at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service. This practice limits the pharmacies that patients can choose from.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report noting that increasing consolidation among PBMs allows the largest six to manage nearly 95% of all U.S. prescriptions.
The FTC expressed concern over the situation, stating that “the leading PBMs now exercise significant power over Americans’ ability to access and afford their prescription drugs.” This dynamic fosters a system where vertically integrated PBMs may prioritize their own affiliated businesses, potentially disadvantaging independent pharmacies and inflating drug prices.
FTC Chair Lina M. Khan pointed out that these middlemen are allegedly “overcharging patients for cancer drugs,” which is leading to an excess revenue of over $1 billion.