A report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients towards higher-priced medications and restricting their access to various pharmacies. This report, which emerged from a 32-month inquiry by the committee, was reviewed before a scheduled hearing involving executives from major PBM companies.
PBMs serve as intermediaries for prescription drug plans available through health insurers, negotiating prices with pharmaceutical firms and determining the out-of-pocket costs experienced by patients. The three primary PBMs in the United States—Express Scripts, OptumRx (a UnitedHealth Group subsidiary), and CVS Health’s Caremark—manage around 80% of all prescriptions filled in the country.
The committee’s findings indicate that PBMs are promoting lists of favored medications that often feature more expensive brand-name drugs instead of more affordable options. An example highlighted in the report is that of emails from Cigna staff which advised against using cheaper alternatives to Humira, a drug used to treat arthritis and other autoimmune conditions, which at the time had an annual cost of $90,000, while a biosimilar was being sold for half that price.
Additionally, the report disclosed that Express Scripts informed patients they would face higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through its mail-order service, effectively limiting patient pharmacy choices.
In a similar vein, the U.S. Federal Trade Commission (FTC) released a report earlier this month stating that an increase in vertical integration among major PBMs allows them to manage nearly 95% of all prescriptions in the U.S. The FTC expressed concerns over the level of control that leading PBMs hold over American patients’ access to affordable medications, revealing potential conflicts of interest between affiliated and independent pharmacies.
FTC Chair Lina M. Khan noted that the findings indicate these intermediaries are “overcharging patients for cancer drugs,” leading to additional profits exceeding $1 billion.