A recent report from the House Committee on Oversight and Accountability has found that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting their pharmacy options. The report, which stems from a 32-month investigation, was shared with the Wall Street Journal prior to a committee hearing featuring executives from the nation’s leading PBMs.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—together manage around 80% of the nation’s prescriptions.
The committee’s findings indicate that these managers are promoting higher-priced brand-name drugs on their preferred drug lists instead of more affordable alternatives. For instance, the report references emails from Cigna employees that discouraged the use of less expensive options for Humira, a treatment for arthritis and other autoimmune disorders that costs around $90,000 annually, despite the availability of a biosimilar at half of that price.
Additionally, the report revealed that Express Scripts informed patients they would pay more for prescriptions filled at local pharmacies than if they obtained a three-month supply from its own mail-order service, thereby limiting patient choices in pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that increasing consolidation among PBMs has allowed the six largest operators to manage nearly 95% of all prescriptions filled in the country. The FTC highlighted concerns over the significant influence these PBMs have over patients’ access to affordable medications and noted potential conflicts of interest arising from PBMs favoring their affiliated businesses.
FTC Chair Lina M. Khan emphasized that the findings demonstrate how these intermediaries may be overcharging patients for vital medications, generating excess revenue exceeding $1 billion in the process.