Pharmacy benefit managers (PBMs) have been criticized for directing patients toward pricier medications and restricting their pharmacy options, according to a recent report by the House Committee on Oversight and Accountability.
The committee’s report, which was examined by the Wall Street Journal, is the result of a 32-month investigation and comes ahead of a congressional hearing featuring leaders from some of the country’s largest PBMs.
PBMs serve as intermediaries for prescription drug plans managed by health insurers, negotiating prices with pharmaceutical companies and determining the out-of-pocket expenses patients face. The three largest PBMs—Express Scripts, OptumRx, and Caremark—account for approximately 80% of all prescriptions filled in the United States.
The report highlights that PBMs have developed lists of preferred medications that favor more expensive brand-name drugs over more affordable alternatives. One example mentioned pointed to internal communications from Cigna that discouraged the use of more affordable substitutes for Humira, a medication used to treat arthritis and other autoimmune disorders that costs around $90,000 annually, despite the availability of a biosimilar at half that price.
Additionally, the report revealed that Express Scripts informed patients they would pay less by obtaining a three-month supply from its affiliated mail-order pharmacy compared to filling prescriptions at a local pharmacy, ultimately limiting patients’ choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report expressing concern over the increasing control exerted by the largest six PBMs, which handle nearly 95% of prescriptions in the U.S. The FTC’s findings indicated that the dominant PBMs significantly impact Americans’ access to and affordability of prescription drugs, creating conflicts of interest that might favor their own affiliated businesses and drive up costs for patients.
FTC Chair Lina M. Khan stated that the revelations show that these intermediaries are “overcharging patients for cancer drugs,” resulting in more than $1 billion in additional revenue for their operations.