A new report by the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards costlier medications while restricting their freedom to choose where to obtain them.
The report follows a 32-month investigation, as reported by the Wall Street Journal, and precedes a committee hearing featuring executives from the largest PBMs in the country. PBMs serve as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket expenses for patients.
The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage around 80% of all prescriptions in the country.
According to the committee’s findings, PBMs have developed preferred drug lists favoring higher-priced brand medications over more affordable options. The report cites instances, including correspondence from Cigna, that discouraged patients from opting for less expensive alternatives to medications like Humira, which had an annual cost of $90,000, despite a biosimilar being available for half that price.
Additionally, the investigation revealed that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, thus limiting patient pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that the largest six PBMs control nearly 95% of all prescriptions filled in the country. The FTC expressed concern over the substantial influence PBMs have on patient access and affordability of medications, warning of conflicts of interest that may arise when PBMs prioritize their affiliated businesses.
FTC Chair Lina M. Khan highlighted the issue of PBMs possibly overcharging patients for cancer treatments, estimating that this practice contributes over $1 billion in additional revenue for these intermediaries.