A new 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 choices for obtaining these drugs.
This report, which has been reviewed by the Wall Street Journal, comes after a lengthy 32-month investigation and precedes a committee hearing featuring executives from the largest PBMs in the country.
PBMs act as intermediaries that manage prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and setting the out-of-pocket costs for patients. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control approximately 80% of U.S. prescriptions.
The findings indicate that PBMs are favoring higher-priced brand-name drugs on their lists of preferred medications, often at the expense of cheaper alternatives. The report highlights that staff at Cigna have discouraged the use of less expensive options, such as biosimilars to Humira, which treats arthritis and other autoimmune conditions, and which cost significantly less than the $90,000 annual price of the brand-name version.
Additionally, patients were informed by Express Scripts that they would end up paying more if they filled prescriptions at local pharmacies compared to using its associated mail-order service, limiting their pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that the top six PBMs now manage nearly 95% of all U.S. prescriptions due to increasing vertical integration and market concentration.
The findings raise concerns about the significant influence PBMs have over Americans’ access to affordable medications, with the FTC noting that this can lead to conflicts of interest and higher drug costs. FTC Chair Lina M. Khan emphasized that these middlemen are overcharging patients for cancer drugs, resulting in an estimated additional revenue of over $1 billion for the PBMs.