A new report from the House Committee on Oversight and Accountability highlights that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications and restricting access to pharmacies.
The findings were revealed in a report seen by the Wall Street Journal, following a 32-month inquiry by the committee prior to a hearing featuring executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and establishing the out-of-pocket costs that patients face. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage about 80% of prescriptions in the U.S.
The committee reported that PBMs have developed preferred drug lists that favor higher-priced brand-name drugs over more affordable alternatives. For instance, it cited emails from Cigna employees that discouraged the use of less expensive options for Humira, a medication for arthritis and other autoimmune diseases, which previously cost around $90,000 annually, while at least one biosimilar was available for half that amount.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs for filling prescriptions at local pharmacies compared to receiving a three-month supply through its affiliated mail-order service, effectively limiting patient choice in pharmacy selection.
The U.S. Federal Trade Commission (FTC) released a related report earlier this month, stating that the increasing concentration and vertical integration within the industry has allowed the six largest PBMs to control nearly 95% of all prescriptions filled in the U.S.
The findings are alarming, with the FTC stating that leading PBMs wield significant power affecting Americans’ access to affordable prescription medications. The report suggested that the vertically integrated PBMs have the potential to favor their own affiliated companies, leading to conflicts of interest that could disadvantage independent pharmacies and escalate prescription drug prices.
According to FTC Chair Lina M. Khan, these issues indicate that these intermediaries are “overcharging patients for cancer drugs,” thereby generating over $1 billion in additional revenue.