A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward higher-priced medications and restricting their options for obtaining prescriptions. This report follows a 32-month investigation ahead of an upcoming hearing involving executives from the largest PBMs in the nation.
PBMs serve as third-party administrators for prescription drug plans, negotiating prices with pharmaceutical companies on behalf of health insurers and determining out-of-pocket costs for patients. The three biggest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage around 80% of prescriptions in the U.S.
The committee’s findings indicate that PBMs have established lists of preferred medications that feature more expensive branded drugs instead of cheaper alternatives. For instance, the report highlights emails from Cigna employees recommending against lower-cost substitutes for Humira, a medication for arthritis and other autoimmune disorders, which was priced at $90,000 annually when a biosimilar was available for half that cost.
Additionally, the committee reported that Express Scripts has informed patients that filling a prescription at their local pharmacy would result in higher costs compared to obtaining a three-month supply from their affiliated mail-order service. This situation appears to restrict patients’ choices regarding pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report, indicating that increasing consolidation has allowed the six largest PBMs to oversee nearly 95% of prescription fills in the country. The findings raised concerns, noting that major PBMs exert substantial influence over Americans’ access to affordable medications. This environment fosters conflicts of interest where vertically integrated PBMs may favor their own businesses over independent pharmacies, driving up prescription costs.
FTC Chair Lina M. Khan stated that the findings demonstrate how these intermediaries are overcharging patients for cancer treatments, resulting in over $1 billion in additional revenue.