Pharmacy-benefit managers (PBMs) are reportedly directing patients towards higher-priced medications while restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability. This findings emerge from a 32-month investigation conducted by the committee in preparation for an upcoming hearing on PBMs that will feature executives from the largest management firms in the country.
PBMs function as intermediaries for prescription drug plans offered by health insurers, negotiating costs with pharmaceutical companies and determining out-of-pocket expenses for patients. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—handle about 80% of all prescriptions.
The report indicates that these managers have devised lists of preferred drugs that prioritize expensive brand-name products over more affordable alternatives. For instance, it references internal communications from Cigna that discouraged the use of less expensive substitutes for Humira, a treatment for arthritis that was priced at $90,000 annually, even though a biosimilar option was available for around half that price.
Additionally, the committee found that Express Scripts informed patients that they would face higher costs if they filled prescriptions at a local pharmacy rather than obtaining a three-month supply from its associated mail-order service. This practice restricts patients’ choices regarding where to fill their prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a related report, highlighting that a concentration of power among the six largest PBMs accounts for nearly 95% of all prescription fills in the country. The FTC expressed concern over the significant influence these leading PBMs have on Americans’ access to affordable medications and the potential conflicts of interest arising from their affiliations, which may disadvantage independent pharmacies.
FTC Chair Lina M. Khan asserted that the findings suggest that PBMs are overcharging patients for vital medications, including cancer drugs, generating extra revenue surpassing $1 billion.