Pharmacy benefit managers (PBMs) are reportedly directing patients toward pricier medications while restricting their access, according to a recent report from the House Committee on Oversight and Accountability.
A 32-month investigation by the committee, which is ahead of an upcoming hearing featuring executives from the largest PBMs, revealed that Medicare patients could potentially save $1.5 billion on ten specific prescription drugs.
The report, which has been reviewed by the Wall Street Journal, highlights the role of PBMs, which act as intermediaries managing prescription drug plans for health insurers. They negotiate prices with pharmaceutical companies and determine out-of-pocket expenses for patients.
The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control roughly 80% of prescription medications in the U.S.
The committee’s findings indicate that these PBMs have established preferred drug lists that favor more expensive branded drugs over less costly alternatives. For instance, emails from Cigna staff noted discouragement towards selecting less expensive options for Humira, a costly treatment for arthritis and other autoimmune diseases that was priced at $90,000 annually at that time. A biosimilar treatment was available at half that cost.
Additionally, Express Scripts informed patients that filling prescriptions at local pharmacies would be more expensive compared to obtaining a three-month supply through their affiliated mail-order service. This practice was viewed as limiting patient choices regarding pharmacy selection.
The U.S. Federal Trade Commission (FTC) released a similar report recently, indicating that increased vertical integration has allowed the six largest PBMs to oversee nearly 95% of prescriptions filled in the United States.
The findings raise concerns, as the FTC noted that these leading PBMs wield considerable influence over Americans’ access to affordable prescription drugs. The report suggests that vertically integrated PBMs may favor their affiliated businesses, leading to conflicts of interest that could disadvantage independent pharmacies and drive up drug prices.
FTC Chair Lina M. Khan emphasized that the revelations indicate that these middlemen are imposing excessive charges on patients for cancer medications, resulting in over $1 billion in additional revenue for them.