Pharmacy-benefit managers (PBMs) are reportedly directing patients toward pricier medications while restricting their options for obtaining these drugs, as highlighted in a recent report by the House Committee on Oversight and Accountability.
According to the Wall Street Journal, the report stems from a 32-month investigation by the committee, which precedes a hearing focusing on PBMs that will feature executives from the nation’s leading management firms.
PBMs serve as intermediaries for prescription drug plans associated with health insurers, negotiating costs with pharmaceutical companies on behalf of health plans. They also determine the out-of-pocket expenses patients incur.
The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—collectively manage approximately 80% of prescription medications in the country.
The committee’s findings indicate that PBMs have developed preferred drug lists prioritizing higher-priced brand-name medications over more affordable alternatives. For instance, the report includes emails from Cigna officials advising against the use of lower-cost substitutes for Humira, a drug that treats arthritis and other autoimmune conditions, and costs around $90,000 annually, despite a biosimilar option being available at half that price.
Furthermore, the committee discovered that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from their affiliated mail-order service. This practice effectively limits patients’ pharmacy choices.
A separate report released earlier this month by the U.S. Federal Trade Commission (FTC) echoed these concerns, indicating that due to increasing vertical integration, the six largest PBMs now manage nearly 95% of prescriptions filled in the U.S.
The FTC’s findings are alarming, stating, “The leading PBMs now exercise significant power over Americans’ ability to access and afford their prescription drugs.” It warns that this situation fosters an environment where vertically integrated PBMs may favor their own associated businesses, leading to conflicts of interest that disadvantage independent pharmacies and escalate prescription drug costs. FTC Chair Lina M. Khan noted that these middlemen are “overcharging patients for cancer drugs,” generating additional revenue exceeding $1 billion.