According to a recent report from the House Committee on Oversight and Accountability, pharmacy-benefit managers (PBMs) are directing patients towards costlier medications while restricting their pharmacy options. This report, which was shared with the Wall Street Journal, is the result of a 32-month investigation and precedes a hearing on PBMs involving leaders from the largest management firms in the country.
PBMs serve as third-party administrators for prescription drug plans associated with health insurers, negotiating prices with pharmaceutical companies and setting out-of-pocket expenses for patients. The three largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—handle approximately 80% of prescriptions in the country.
The findings revealed that PBMs have developed lists of preferred medications that prioritize higher-priced brand name drugs over more affordable options. An example highlighted in the report includes internal communications from Cigna discouraging the use of cheaper alternatives to Humira, a treatment for arthritis costing around $90,000 annually, despite the availability of biosimilars at half that price.
Additionally, the report indicated that Express Scripts informed patients they would incur higher costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, thereby limiting patient choice regarding pharmacy selection.
A similar report was released earlier this month by the U.S. Federal Trade Commission (FTC), which noted that increasing vertical integration and concentration in the market has allowed the six largest PBMs to control nearly 95% of all prescriptions filled in the U.S.
The findings raised concerns about the significant influence PBMs have over patients’ access to affordable prescription drugs. The FTC emphasized that vertically integrated PBMs might favor their affiliated businesses, potentially disadvantaging independent pharmacies and escalating drug costs.
FTC Chair Lina M. Khan stated that these intermediaries are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.