A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards costlier medications and restricting their options for obtaining them.
This report stems from a 32-month investigation conducted by the committee in advance of a hearing featuring executives from the largest PBMs in the country. PBMs serve as third-party administrators of prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining the out-of-pocket expenses for patients.
The report highlights that the three leading PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of all U.S. prescriptions. The findings indicate that these managers favor more expensive brand-name drugs on their lists of preferred medications over cheaper alternatives. For instance, the committee cited correspondence from Cigna employees discouraging the use of less expensive options for Humira, a medication for arthritis and autoimmune conditions, which costs about $90,000 annually, although a biosimilar was available for half that price.
Additionally, the committee noted that Express Scripts informed patients that filling prescriptions at local pharmacies would result in higher costs than obtaining a three-month supply from its affiliated mail-order service. This practice limits patient choice regarding pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report. It revealed that increased vertical integration has allowed the six largest PBMs to manage nearly 95% of prescriptions filled in the country. The FTC’s report described the situation as troubling, indicating that leading PBMs now wield considerable influence over Americans’ access to and affordability of prescription drugs. This creates a system in which vertically integrated PBMs may prioritize their own affiliated businesses, leading to potential conflicts of interest that disadvantage independent pharmacies and inflate prescription costs.
FTC Chair Lina M. Khan stated that the findings demonstrate how these intermediaries are overcharging patients for cancer medications, generating an excess of more than $1 billion in additional revenue.