Pharmacy-benefit managers (PBMs) are directing patients towards pricier medications and restricting their choices regarding where they can obtain these drugs, according to a recent report from the House Committee on Oversight and Accountability.
The report, which was reviewed by the Wall Street Journal, is the result of a 32-month investigation by the committee and comes ahead of a hearing involving executives from major PBM companies.
PBMs are essentially third-party administrators for prescription drug plans, negotiating drug prices with pharmaceutical companies on behalf of health insurers. They also determine the out-of-pocket expenses that patients must pay.
The three largest PBMs in the United States—Express Scripts, OptumRx (UnitedHealth Group), and CVS Health’s Caremark—control about 80% of all prescriptions filled.
Findings from the committee indicate that PBMs have developed lists of preferred medications that prioritize higher-cost brand-name drugs over more affordable alternatives. For instance, the report highlights communications from Cigna staff discouraging the use of less expensive alternatives to Humira, a drug for arthritis and other autoimmune conditions that costs approximately $90,000 annually, despite the availability of a biosimilar for around half that price.
Additionally, the report reveals that Express Scripts informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, thereby limiting patient choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that increased vertical integration among the largest PBMs has enabled them to manage nearly 95% of all U.S. prescriptions filled.
The findings are concerning, with the FTC stating that leading PBMs wield considerable influence over Americans’ access to and affordability of prescription medications. The situation fosters a landscape where vertically integrated PBMs may favor their affiliated businesses, creating conflicts of interest that could disadvantage independent pharmacies and raise prescription drug costs.
FTC Chair Lina M. Khan noted that these middlemen are reportedly overcharging patients for cancer medications, generating over $1 billion in additional revenue for themselves.