Pharmacy-benefit managers (PBMs) are reportedly guiding patients towards more expensive medications and restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability.
The report, which was reviewed by the Wall Street Journal, emerged after a 32-month investigation conducted by the committee in advance of a hearing featuring executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans associated with health insurers. They negotiate prices with pharmaceutical companies for how much health plans will pay for medications and also determine patients’ out-of-pocket costs.
The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (a subsidiary of CVS Health)—manage around 80% of prescriptions across the country.
The House committee’s findings indicated that PBMs have developed lists of preferred drugs that favor higher-cost brand-name products over less expensive alternatives. For instance, the report highlights internal communications from Cigna that discouraged opting for cheaper alternatives to Humira, an arthritis treatment that had an annual price of $90,000 at that time, even though at least one biosimilar was available for approximately half that price.
Additionally, the committee found that Express Scripts informed patients that they would incur higher costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply through its affiliated mail-order pharmacy. This practice was seen as a limitation on patient choice concerning pharmacy selection.
A similar report issued by the U.S. Federal Trade Commission earlier this month noted that “increasing vertical integration and concentration” has allowed the six largest PBMs to manage nearly 95% of all prescriptions dispensed in the United States.
The findings raised concerns about the significant influence of leading PBMs on American access to and affordability of prescription drugs. The FTC highlighted that the structure allows vertically integrated PBMs to favor their own businesses, resulting in conflicts of interest that can be detrimental to independent pharmacies and escalate drug costs.
FTC Chair Lina M. Khan stated that the findings indicate these intermediaries are “overcharging patients for cancer drugs,” yielding them additional revenue exceeding $1 billion.