A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications and restricting their pharmacy options.
The findings, which were shared with the Wall Street Journal, emerge from a 32-month investigation by the committee and precede a hearing involving executives from the largest PBM companies in the U.S.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating prices with drug manufacturers and determining out-of-pocket costs for patients. The three largest PBMs—Express Scripts, OptumRx, and Caremark—handle about 80% of prescriptions in the United States.
The report claims that PBMs have developed preferred drug lists that favor pricier brand-name medications over cheaper alternatives. For instance, it mentions that Cigna staff discouraged the use of lower-cost biosimilars for Humira, which treats arthritis and autoimmune conditions and was priced at $90,000 annually, while a biosimilar was available for half that amount.
Additionally, the committee found that Express Scripts informed patients they would pay more at local pharmacies compared to ordering a three-month supply from its affiliated mail-order service, limiting patient choice in pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that increased vertical integration among PBMs allows the six largest companies to manage nearly 95% of all U.S. prescriptions.
The report’s implications are concerning. The FTC noted that the leading PBMs wield significant influence over Americans’ access to and affordability of prescription drugs. There are concerns about conflicts of interest that arise from PBMs favoring their own affiliated businesses, potentially disadvantaging independent pharmacies and driving up drug prices.
FTC Chair Lina M. Khan pointed out that these middlemen are reportedly overcharging patients for cancer medications, leading to an extra billion dollars in revenue.