A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting options for where those drugs can be obtained. This report follows a 32-month investigation by the committee, which is anticipating a hearing with leaders from the country’s major PBMs.
PBMs serve as third-party administrators for prescription drug plans offered by health insurers. They negotiate pricing with pharmaceutical companies and determine the out-of-pocket expenses for patients.
The report highlights that the three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control roughly 80% of prescriptions filled in the United States.
According to the findings, PBMs often compile lists of preferred drugs that prioritize higher-priced branded medications over less expensive alternatives. For instance, emails from Cigna staff were mentioned in the report, indicating a discouragement of cheaper substitutes for Humira, a treatment for various autoimmune conditions that was priced at $90,000 annually, despite the existence of a biosimilar costing half that amount.
Additionally, the committee discovered that Express Scripts informed patients they would incur greater expenses by filling prescriptions at their local pharmacies than if they opted for a three-month supply through their mail-order service, which narrows patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, noting that increased vertical integration among PBMs enables the six largest managers to oversee nearly 95% of all prescriptions filled in the country. The FTC expressed concern over the significant power PBMs wield over Americans’ access to and affordability of prescription medications. They also indicated a potential conflict of interest, as these entities may favor their affiliated businesses, putting independent pharmacies at a disadvantage.
FTC Chair Lina M. Khan emphasized the serious implications of these findings, stating that these middlemen are overcharging patients for cancer treatments, yielding them an additional revenue of over $1 billion.