A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting where they can obtain them.
The report, which followed a 32-month investigation, was shared with the Wall Street Journal ahead of a hearing featuring executives from the country’s largest PBMs. PBMs serve as intermediaries managing prescription drug plans for health insurers and negotiate prices between pharmaceutical companies and health plans. They also determine patients’ out-of-pocket expenses.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of all prescriptions filled in the country.
Findings from the committee’s report indicate that these managers have created lists of preferred medications that favor higher-priced brand name drugs over more affordable alternatives. The report highlights instances, such as emails from Cigna which discouraged using cheaper substitutes for Humira, an arthritis and autoimmune treatment that costs approximately $90,000 annually, even though a biosimilar was available for half that price.
Additionally, Express Scripts reportedly informed patients that filling prescriptions at local pharmacies would be costlier than obtaining a three-month supply from its mail-order pharmacy, effectively limiting patient pharmacy choices.
A similar report was released by the U.S. Federal Trade Commission (FTC) earlier this month, which stated that the six largest PBMs collectively handle nearly 95% of all prescriptions filled in the U.S. The FTC’s findings raised concerns, stating that leading PBMs have significant influence over patients’ access to affordable medications.
FTC Chair Lina M. Khan noted that the data suggests these middlemen are overcharging patients for cancer treatments, generating over $1 billion in excess revenue from these practices.