A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are pushing patients towards more expensive medications and restricting their pharmacy options.
The findings follow a 32-month investigation and come ahead of a hearing featuring executives from the nation’s leading PBMs. PBMs operate as third-party administrators for prescription drug plans, negotiating with pharmaceutical companies on prices and determining out-of-pocket costs for patients. The three largest PBMs in the U.S. — Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark — control approximately 80% of prescriptions filled in the country.
The report indicates that PBMs have created ‘preferred drug’ lists that favor higher-cost brand name medications instead of more affordable alternatives. For instance, the report highlights emails from Cigna that discouraged the prescription of cheaper substitutes for Humira, a treatment for arthritis and other autoimmune diseases, which had a yearly cost of $90,000, despite the availability of a biosimilar priced at half that amount.
Additionally, the committee found that Express Scripts informed patients they would incur higher costs for prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service. This practice restricts patient choice concerning their preferred pharmacies.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that increased vertical integration has allowed the six largest PBMs to manage nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern over the significant influence the leading PBMs have on Americans’ access to affordable prescription medications. The findings suggest a system where vertically integrated PBMs may favor their affiliated businesses, potentially disadvantaging independent pharmacies and raising drug costs.
FTC Chair Lina M. Khan remarked that the findings illustrate how PBMs are overcharging patients for crucial medications, including cancer drugs, generating over $1 billion in additional revenue.