Pharmacy-benefit managers (PBMs) are reportedly directing patients toward more expensive medications and restricting their access to pharmacies, according to a recent report from the House Committee on Oversight and Accountability.
This report, which was obtained by the Wall Street Journal, follows a 32-month inquiry by the committee prior to a hearing featuring executives from the country’s leading PBMs.
PBMs act as third-party administrators for prescription drug plans on behalf of health insurers. They negotiate with drug manufacturers regarding the prices that health plans pay for medications, as well as determine patients’ out-of-pocket costs.
Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark are the three largest PBMs in the U.S., collectively managing about 80% of the prescriptions filled nationwide.
The committee’s findings indicated that PBMs have formulated preferred drug lists that favor higher-priced brand-name drugs over more affordable options. For instance, the report highlights emails from Cigna staff discouraging the use of less expensive alternatives to Humira, a treatment for arthritis and other autoimmune diseases that cost around $90,000 annually. At the time, there was a biosimilar available for approximately half that price.
Additionally, Express Scripts informed patients that filling a prescription at a local pharmacy would generally cost them more than obtaining a three-month supply from their affiliated mail-order service, which the committee noted restricted patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that increasing integration among PBMs allows the largest six players to manage nearly 95% of all prescriptions in the U.S.
The situation raises serious concerns. The FTC stated, “The leading PBMs now exert considerable power over Americans’ access to and affordability of prescription drugs,” and highlighted how vertically integrated PBMs could prioritize their own affiliate services, disadvantaging independent pharmacies and raising drug costs.
FTC Chair Lina M. Khan pointed out that these middlemen are “overcharging patients for cancer drugs,” generating additional revenue exceeding $1 billion.