Pharmacy benefit managers (PBMs) are reportedly guiding patients towards more expensive medications while restricting where they can obtain them, according to a recent report from the House Committee on Oversight and Accountability.
The report, examined by the Wall Street Journal, comes after a 32-month investigation conducted by the committee ahead of a hearing involving executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans on behalf of 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 — oversee about 80% of prescriptions in the nation.
The committee’s findings indicated that these PBMs have curated lists of preferred medications that feature higher-priced brand-name drugs instead of more affordable options. For instance, the report highlighted communications from Cigna staff discouraging the use of cheaper alternatives to Humira, a costly treatment for arthritis and other autoimmune disorders. At that time, Humira was priced at $90,000 annually, while at least one biosimilar was available for around half that cost.
Additionally, the report revealed that Express Scripts informed patients they would incur higher expenses by filling prescriptions at their local pharmacies rather than receiving a three-month supply through their mail-order pharmacy. This practice effectively restricted patients’ choices regarding where they could fill their prescriptions.
A similar report released earlier this month by the U.S. Federal Trade Commission found that the largest six PBMs now manage nearly 95% of all prescriptions filled in the United States due to increasing vertical integration and concentration in the industry.
These developments raise concerns as the FTC stated, “The leading PBMs now exercise significant power over Americans’ ability to access and afford their prescription drugs.” It also noted that the system appears to encourage vertically integrated PBMs to prefer their own affiliated businesses, leading to conflicts of interest that can disadvantage non-affiliated pharmacies and drive up drug costs.
FTC Chair Lina M. Khan commented on the findings, stating that intermediaries are “overcharging patients for cancer drugs,” resulting in over $1 billion in additional revenue for them.