Pharmacy-benefit managers (PBMs) are directing patients towards more costly medications and restricting their pharmacy options, as revealed in a recent report from the House Committee on Oversight and Accountability. The Wall Street Journal examined this report, which was based on a 32-month investigation leading up to a committee hearing involving leaders from the largest PBMs in the country.
PBMs act as intermediaries for health insurers, handling prescription drug plans. They negotiate prices with pharmaceutical companies and determine patients’ out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage approximately 80% of all prescriptions.
According to the report, these managers have been favoring higher-priced brand-name drugs over less expensive alternatives on their preferred drug lists. An example highlighted was communication from Cigna discouraging the use of affordable alternatives to Humira, a treatment costing $90,000 annually, even though at least one biosimilar was available for about half that price.
Additionally, Express Scripts reportedly informed patients that they would incur higher costs when filling prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service. This practice allegedly limited patients’ options for pharmacies.
A similar report released by the U.S. Federal Trade Commission (FTC) earlier this month indicated that the consolidation and vertical integration of the industry have allowed the six largest PBMs to control nearly 95% of U.S. prescription fills. The FTC expressed concern over the considerable influence PBMs have on American patients’ access to affordable medications. The report suggested that the integrated nature of these PBMs may promote conflicts of interest, disadvantaging independent pharmacies and escalating drug prices.
FTC Chair Lina M. Khan stated that the findings illustrate how these intermediaries are inflating costs for patients, particularly with cancer treatments, resulting in over $1 billion in additional revenues for them.