According to a recent report by the House Committee on Oversight and Accountability, pharmacy-benefit managers (PBMs) are directing patients towards more costly medications and restricting their options for obtaining these drugs.
The report, which followed a 32-month investigation and was reviewed by the Wall Street Journal, precedes a hearing involving executives from the largest PBM companies in the country. PBMs serve as third-party administrators for prescription drug plans, negotiating prices with pharmaceutical companies and determining out-of-pocket costs for patients.
The three largest PBMs in the U.S.—Express Scripts, OptumRx (owned by UnitedHealth Group), and Caremark (part of CVS Health)—manage roughly 80% of prescriptions in the country. The committee’s findings indicate that these managers often promote preferred drug lists that favor higher-priced brand-name drugs rather than cheaper alternatives.
An example highlighted in the report referred to emails from Cigna that discouraged the use of less expensive options for Humira, a medication for arthritis and autoimmune diseases priced at $90,000 annually, despite the availability of a biosimilar at half that cost.
The committee also discovered that Express Scripts informed patients they could end up paying more at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, which restricted patient choices regarding pharmacies.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report, stating that increased vertical integration among the six largest PBMs allows them to oversee nearly 95% of all prescriptions filled in the United States.
The FTC expressed concern over the findings, noting that leading PBMs wield substantial influence over patients’ ability to access and afford medications. This trend raises potential conflicts of interest, as vertically integrated PBMs seemingly favor their own related businesses, disadvantaging non-affiliated pharmacies and driving up drug costs.
FTC Chair Lina M. Khan remarked that these middlemen have been “overcharging patients for cancer drugs,” contributing more than $1 billion in additional revenue.