A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications and restricting their pharmacy options.
The findings, published by the Wall Street Journal, come after a 32-month investigation ahead of a hearing involving executives from major PBMs in the country. PBMs, which act as intermediaries for prescription drug plans for health insurers, negotiate prices with pharmaceutical companies and determine the 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 approximately 80% of U.S. prescriptions.
The committee’s report indicates that these PBMs have developed lists of preferred drugs, often favoring higher-priced brand-name drugs over less costly alternatives. For instance, the report points out communications from Cigna staff discouraging the use of cheaper alternatives to Humira, a drug used for arthritis and other autoimmune conditions that was priced at $90,000 per year at the time, despite the availability of biosimilars at half the cost.
Furthermore, the committee found instances where Express Scripts informed patients they would face higher costs for prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order pharmacy, thereby limiting patient choices.
In a related report, the U.S. Federal Trade Commission (FTC) warned about increased vertical integration within the industry, stating that the six largest PBMs manage nearly 95% of all prescriptions filled in the U.S.
The FTC’s findings raise significant concerns. They highlighted that leading PBMs wield considerable control over Americans’ access to affordable prescription medications. The report also indicated that vertically integrated PBMs may prioritize their own affiliated businesses, creating conflicts of interest that could harm unaffiliated pharmacies and drive up drug costs.
FTC Chair Lina M. Khan emphasized that these middlemen are effectively overcharging patients for cancer drugs, generating over $1 billion in additional revenue.