Pharmacy benefit managers (PBMs) are directing patients towards higher-priced medications while restricting their options for obtaining these drugs, as highlighted in a recent report from the House Committee on Oversight and Accountability.
This report, which was reviewed by the Wall Street Journal, emerges from a 32-month investigation conducted by the committee in anticipation of a hearing featuring executives from the largest PBMs in the U.S.
PBMs serve as intermediaries for prescription drug plans offered by health insurers, negotiating costs with pharmaceutical companies and determining the out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, OptumRx, and Caremark—control approximately 80% of prescriptions dispensed in the United States.
According to the committee’s findings, PBMs have established preferred drug lists that favor higher-priced brand-name medications over more affordable generic options. Notably, the report includes communications from Cigna staff discouraging the use of less expensive alternatives to Humira, a drug for arthritis and autoimmune conditions, which was priced at $90,000 annually when a biosimilar was available for about half that price.
The investigation also revealed that Express Scripts informed patients they would incur greater costs by using local pharmacies instead of obtaining a three-month supply through their affiliated mail-order service, effectively limiting patient choices regarding where to fill prescriptions.
A similar report from the U.S. Federal Trade Commission (FTC) published earlier this month echoed these concerns, indicating that increasing consolidation has allowed the six largest PBMs to oversee nearly 95% of all prescriptions filled in the country.
The findings present alarming implications. The FTC noted that leading PBMs wield considerable influence over Americans’ access to and affordability of prescription medications, and they tend to favor their own affiliated businesses, leading to potential conflicts of interest that adversely affect independent pharmacies and escalate drug prices.
FTC Chair Lina M. Khan emphasized that the revelations demonstrate how these intermediaries are overcharging patients for cancer treatments, generating additional revenues exceeding $1 billion.