A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications and restricting their pharmacy options.
The findings come after a 32-month investigation by the committee, which precedes a hearing involving key executives from the largest PBMs in the U.S. PBMs act as intermediaries for health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket costs.
The three largest PBMs in the country—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of U.S. prescriptions. According to the report cited by the Wall Street Journal, these managers have established lists of preferred medications that favor higher-priced brand-name drugs over more affordable generic alternatives.
One example highlighted in the report involves Cigna staff emails that discouraged the use of more affordable substitutes for Humira, a treatment for arthritis and other autoimmune disorders, which was priced at $90,000 annually, despite the availability of a biosimilar option at half that cost.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from their affiliated mail-order service. This strategy was deemed to limit patients’ choices regarding where to fill their prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that the growing integration and concentration among PBMs has allowed the six largest firms to manage almost 95% of all prescriptions filled in the nation.
The FTC’s findings raise concerns about the significant influence that leading PBMs have on Americans’ access to affordable medications. It highlighted a potential conflict of interest, where vertically integrated PBMs may prefer their own affiliated businesses, potentially disadvantaging independent pharmacies and inflating prescription costs.
FTC Chair Lina M. Khan noted that these middlemen could be overcharging patients for cancer medications, resulting in an excess revenue of over $1 billion.