A new report from the House Committee on Oversight and Accountability suggests that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their options for obtaining these drugs. This report, obtained by the Wall Street Journal, comes after a lengthy 32-month investigation ahead of a hearing involving executives from the largest PBM firms in the nation.
PBMs serve as third-party administrators for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and establishing the out-of-pocket expenses that patients incur. The three largest PBMs in the U.S.—Express Scripts, OptumRx (UnitedHealth Group), and Caremark (CVS Health)—oversee around 80% of prescriptions in the country.
The committee’s findings indicate that PBMs have been promoting lists of preferred medications that include higher-priced brand-name drugs rather than less expensive alternatives. For instance, the report highlights internal communications from Cigna that discouraged using biosimilars for Humira, a medication for arthritis and other autoimmune diseases priced at $90,000 annually, when a comparable option was available for half that cost.
Additionally, Express Scripts allegedly informed patients that they would pay more at local pharmacies compared to obtaining a three-month supply through their affiliated mail-order services, thereby limiting patient choice in pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that six major PBMs now manage nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern over the significant power PBMs wield over patient access to affordable medications. The report noted that this vertical integration could lead to potential conflicts of interest that disadvantage independent pharmacies and inflate drug costs.
FTC Chair Lina M. Khan remarked that these intermediaries are allegedly “overcharging patients for cancer drugs,” leading to over $1 billion in additional revenue for them.