Pharmacy benefit managers (PBMs) are allegedly directing patients toward more expensive medications while restricting their access to various pharmacies, according to a recent report by the House Committee on Oversight and Accountability.
The report, which followed a 32-month investigation and was reviewed by the Wall Street Journal, comes ahead of a hearing involving executives from the largest PBMs in the country.
PBMs serve as third-party administrators for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies for drugs and determining patients’ out-of-pocket costs. The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—manage roughly 80% of the nation’s prescriptions.
According to the findings of the committee’s report, these PBMs have developed lists that favor high-priced brand-name drugs over more affordable alternatives. An example highlighted in the report shows that Cigna staff discouraged the use of cheaper substitutes for Humira, a drug for arthritis and other autoimmune disorders that had an annual cost of $90,000. A biosimilar was available for about half that price.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs by using their local pharmacy, compared to obtaining a three-month supply through its affiliated mail-order service, which limits patients’ pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that rising consolidation in the industry has allowed the six largest PBMs to control nearly 95% of prescriptions in the U.S. The FTC’s findings raised concerns, noting that the leading PBMs now wield significant influence over Americans’ access to affordable medications. It indicated that the vertically integrated nature of these PBMs could lead to conflicts of interest that ultimately disadvantage independent pharmacies and elevate drug prices.
FTC Chair Lina M. Khan remarked that the findings reveal how these intermediaries are overcharging patients for cancer medications, generating an extra revenue exceeding $1 billion.