Pharmacy benefit managers (PBMs) are directing patients towards more expensive medications and restricting their options for obtaining 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 in anticipation of an upcoming hearing featuring executives from the nation’s leading PBMs.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket costs.
The three largest PBMs in the U.S., Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark, manage around 80% of all prescriptions filled.
Findings from the committee’s report indicate that PBMs often promote a selection of preferred drugs that include higher-priced brand-name medications over more affordable alternatives. For instance, the report references internal emails from Cigna that advised against using less expensive options for Humira, a treatment for arthritis and other autoimmune diseases that was priced at $90,000 annually at the time, even though at least one biosimilar version was available for half that cost.
Additionally, the committee discovered that Express Scripts informed patients they would pay more at their local pharmacy compared to obtaining a three-month supply from its affiliated mail-order pharmacy, a move that effectively limited patient pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, noting that the increasing integration and concentration of PBMs has allowed the six largest PBMs to control nearly 95% of all U.S. prescriptions.
The implications of these findings are concerning. The FTC stated, “The leading PBMs now exercise significant power over Americans’ ability to access and afford their prescription drugs.” It also pointed out that the current system generates conflicts of interest, as vertically integrated PBMs may prefer their own associated businesses, potentially disadvantaging independent pharmacies and driving up drug prices.
FTC Chair Lina M. Khan highlighted that these middlemen are “overcharging patients for cancer drugs,” leading to an additional revenue of over $1 billion for these entities.