Pharmacy-benefit managers (PBMs) are reportedly guiding patients toward more costly medications and restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability.
This revelation comes as McDonald’s is now facing its first lawsuit linked to the E. coli outbreak associated with its Quarter Pounder.
The report, reviewed by the Wall Street Journal, follows a 32-month investigation by the committee in anticipation of a hearing featuring executives from the country’s largest PBMs.
PBMs act as third-party administrators for prescription drug plans offered by health insurers. They negotiate with drug manufacturers to determine the costs that health plans will cover for specific medications and also set out-of-pocket costs for patients.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage around 80% of prescriptions issued in the country.
Findings from the committee’s report indicate that PBMs have established preferred drug lists that prioritize higher-priced brand names over cheaper alternatives. For instance, the report mentions emails from Cigna personnel who discouraged using less expensive options to Humira, a treatment for arthritis and similar autoimmune conditions, which had a cost of $90,000 annually. At least one biosimilar was available for about half this price.
Additionally, the committee discovered that Express Scripts informed patients that filling a prescription at their local pharmacy would be more expensive than obtaining a three-month supply from its affiliated mail-order service. This practice limits patients’ choices regarding which pharmacy they can utilize.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report. The FTC noted that heightened vertical integration and concentration have permitted the six largest PBMs to manage almost 95% of all prescriptions filled in the United States.
The findings raise concerns as the FTC stated that leading PBMs now wield significant influence over Americans’ access to and affordability of prescription medications. This situation fosters a system where vertically integrated PBMs might favor their own affiliated businesses, leading to conflicts of interest that could disadvantage non-affiliated pharmacies and drive up prescription costs.
FTC Chair Lina M. Khan remarked that the findings reveal that these intermediaries are overcharging patients for cancer drugs, generating additional revenue exceeding $1 billion.