A new report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their options for obtaining those medications. The findings emerged from a 32-month investigation in advance of a hearing featuring executives from the nation’s leading PBMs.
PBMs act as intermediaries for prescription drug plans managed by health insurers, negotiating prices with pharmaceutical companies on behalf of health plans and determining patients’ out-of-pocket expenses. The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of prescription medications dispensed in the country.
The report noted that PBMs have compiled lists that favor higher-priced brand-name drugs over more affordable alternatives. One example includes emails from Cigna staff discouraging the use of cheaper alternatives to Humira, a medication for arthritis and other autoimmune diseases, which was priced at $90,000 annually at that time, despite the availability of a biosimilar at about half the cost.
Additionally, the committee reported that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies than by obtaining a three-month supply through its affiliated mail-order service, thus limiting their pharmacy choices.
This follows a recent interim report from the U.S. Federal Trade Commission (FTC), which indicated that increasing concentration and vertical integration have allowed the six largest PBMs to dominate nearly 95% of all prescriptions in the U.S. The FTC expressed concern over the significant power these PBMs have over Americans’ access to affordable medications, revealing that long-term affiliations may create conflicts of interest that adversely affect independent pharmacies and drive up drug prices.
FTC Chair Lina M. Khan highlighted that these intermediaries are “overcharging patients for cancer drugs,” leading to an additional revenue stream exceeding $1 billion.