A new report from the House Committee on Oversight and Accountability highlights concerns about pharmacy-benefit managers (PBMs) steering patients toward more expensive medications and limiting their options for obtaining these drugs. The findings come ahead of an upcoming hearing featuring executives from the country’s largest PBMs, following a 32-month investigation.
PBMs act as intermediaries between health insurers and pharmaceutical companies, negotiating prices for medications and determining patient out-of-pocket costs. The three largest PBMs in the U.S. — Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark — control about 80% of prescription medications in the country.
The report indicates that PBMs often compile lists of preferred drugs that favor higher-priced brand-name medications over more affordable alternatives. An example given includes communications from Cigna, which discouraged the use of lower-cost substitutes for Humira, an expensive treatment for autoimmune conditions priced at $90,000 annually, despite the availability of a biosimilar at half that cost.
Additionally, the investigation found that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its mail-order service, thereby restricting patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) published a related report, indicating that the six largest PBMs dominate nearly 95% of all prescriptions filled in the United States. The FTC’s findings raised concerns over the considerable power these PBMs hold over patients’ access to affordable medications, suggesting it creates conflicts of interest that could disadvantage non-affiliated pharmacies and drive up drug costs.
FTC Chair Lina M. Khan expressed that these findings reveal that PBMs are overcharging patients for cancer drugs, leading to over $1 billion in additional revenue for these middlemen.