Pharmacy benefit managers (PBMs) are directing patients toward costlier medications while restricting access to them, according to a recent report from the House Committee on Oversight and Accountability. The findings follow a 32-month investigation by the committee and precede a hearing involving executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket costs. Express Scripts, OptumRx (owned by UnitedHealth Group), and Caremark (part of CVS Health) dominate the market, managing around 80% of prescriptions in the United States.
The committee’s report reveals that PBMs have compiled lists of preferred drugs favoring higher-priced brand-name medications over cheaper alternatives. For instance, it highlights communications from Cigna staff that discouraged the use of lower-cost substitutes for Humira, a treatment for autoimmune disorders, which was priced at $90,000 annually, despite the availability of a biosimilar for half that price.
Moreover, the report indicates 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 mail-order pharmacy, thereby limiting patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report acknowledging that the increasing consolidation of PBMs has allowed the six largest firms to oversee almost 95% of all prescriptions in the country. The FTC expressed concern that leading PBMs possess considerable influence over Americans’ ability to access and afford medications, contributing to an environment where vertically integrated PBMs may prioritize their own affiliated businesses, leading to conflicts of interest that disadvantage independent pharmacies and escalate drug costs.
FTC Chair Lina M. Khan remarked that the findings indicate PBMs are overcharging patients for cancer medications, resulting in an additional revenue of over $1 billion for these intermediaries.