A recent report from the House Committee on Oversight and Accountability indicates that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications while restricting their pharmacy options. This report comes after a 32-month investigation and is related to an upcoming hearing featuring executives from major PBMs.
PBMs, operating as third-party administrators for prescription drug plans provided by health insurers, negotiate costs with pharmaceutical companies and determine patient out-of-pocket expenses. The three largest PBMs—Express Scripts, OptumRx, and Caremark—account for about 80% of prescriptions filled in the United States.
According to the committee’s findings, the PBMs have developed preferred drug lists that prioritize higher-priced brand-name medications over more affordable alternatives. An example cited in the report includes correspondence from Cigna employees that discouraged patients from using cheaper substitutes for Humira, a medication for arthritis and autoimmune conditions with an annual cost of $90,000, despite the availability of a biosimilar at half that price.
The committee also highlighted that Express Scripts informed patients they would incur higher costs for prescriptions if filled at local pharmacies compared to those sourced through its affiliated mail-order service, thereby limiting patients’ pharmacy choices.
This report coincides with a similar one released by the U.S. Federal Trade Commission (FTC), which noted that the largest six PBMs manage nearly 95% of prescriptions in the U.S. The FTC’s interim report expressed concerns over the substantial influence these PBMs hold over Americans’ access to affordable medications, suggesting that the vertical integration of these companies may lead to conflicts of interest that disadvantage independent pharmacies and increase drug costs.
FTC Chair Lina M. Khan highlighted that these findings illustrate how PBMs are allegedly overcharging patients for cancer medications, reportedly generating over $1 billion in extra revenue from these practices.