According to a recent report from the House Committee on Oversight and Accountability, pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their access to different pharmacies.
The investigation, which lasted for 32 months, was reviewed by the Wall Street Journal prior to a committee hearing featuring executives from the largest PBM companies in the country. PBMs serve as third-party administrators for prescription drug plans, negotiating prices with pharmaceutical companies on behalf of health insurers and determining the out-of-pocket expenses for patients.
The three largest PBMs in the United States—Express Scripts, OptumRx (a subsidiary of UnitedHealth Group), and Caremark (part of CVS Health)—manage around 80% of U.S. prescriptions. The report highlighted that these PBMs have developed preferred drug lists that often favor higher-priced brand-name drugs over more affordable alternatives.
An example given in the report includes correspondence from Cigna employees advising against selecting cheaper equivalents to Humira, a medication for arthritis and other autoimmune diseases that costs $90,000 annually, despite the availability of a biosimilar at half that price.
Additionally, the committee noted that Express Scripts informed patients they would incur greater costs if they obtained prescriptions from local pharmacies as opposed to using its affiliated mail-order service, which further restricted patient choice in pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission released a similar report indicating that the six largest PBMs now control nearly 95 percent of all prescriptions filled in the country due to increasing vertical integration and market concentration.
The FTC expressed concern over the influence these leading PBMs have on Americans’ access to affordable prescription drugs, stating that their operations could introduce conflicts of interest by favoring their own affiliated businesses, which might hinder unaffiliated pharmacies and escalate drug costs. FTC Chair Lina M. Khan noted that findings indicate these middlemen have been overcharging patients for cancer treatments, resulting in additional revenues exceeding $1 billion.