A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly prescription medications while restricting their choices of pharmacies.
The report, obtained by the Wall Street Journal, follows a 32-month investigation prior to an upcoming hearing featuring executives from the largest PBM firms in the country.
PBMs serve as intermediaries for health insurers, administering prescription drug plans and negotiating prices with pharmaceutical manufacturers. They also determine the out-of-pocket expenses patients must incur. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control approximately 80% of the nation’s prescriptions.
The committee’s findings indicate that PBMs often compile lists of preferred medications that prioritize higher-cost brand-name drugs over more economical alternatives. An example from the report mentions internal communications from Cigna that discouraged the use of lower-cost alternatives for Humira, a treatment for arthritis and other autoimmune disorders, which was priced at $90,000 annually, despite the availability of a biosimilar at half that cost.
Furthermore, the report points out that Express Scripts informed patients that obtaining a three-month prescription through its affiliated mail-order service would be cheaper than filling their prescriptions at local pharmacies, effectively limiting patient choices.
Earlier this month, the U.S. Federal Trade Commission released a similar report, noting that increasing consolidation among PBMs has allowed the six largest managers to oversee nearly 95% of all prescriptions filled in the U.S.
The findings raise concerns about the significant influence PBMs wield over American patients’ access to affordable medications. The FTC highlighted potential conflicts of interest arising from the vertical integration of PBMs, which may prioritize their own affiliated businesses, disadvantaging independent pharmacies and driving up drug prices.
FTC Chair Lina M. Khan stated that these practices have resulted in patients being overcharged for cancer treatments, generating an additional $1 billion in revenue for the middlemen.