A new report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications and restricting their pharmacy choices.
The report, which followed a 32-month investigation, is timely ahead of a hearing featuring executives from the largest PBMs in the nation. PBMs act as intermediaries for health insurers in managing prescription drug plans, negotiating prices with pharmaceutical companies and determining the out-of-pocket expenses for patients.
The three major PBMs—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—control about 80% of U.S. prescriptions. The committee found that these companies often maintain preferred drug lists that favor higher-priced brand-name medications over less expensive alternatives.
For instance, the report mentions emails from Cigna employees that discouraged using cheaper alternatives for Humira, a medication for arthritis and other autoimmune disorders that cost around $90,000 annually, despite the availability of biosimilars at roughly half that price.
Additionally, it was revealed that Express Scripts informed patients that they could pay more for their prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service, effectively limiting patient choice in pharmacies.
A recent report from the U.S. Federal Trade Commission also echoed these concerns, indicating that the six largest PBMs manage nearly 95% of all prescriptions in the U.S., giving them considerable influence over drug accessibility and affordability. The FTC highlighted that this dominance may lead to conflicts of interest, as vertically integrated PBMs might favor their own businesses, potentially disadvantaging independent pharmacies and increasing drug costs.
FTC Chair Lina M. Khan noted that these findings indicate that PBMs are overcharging patients for cancer treatments, generating over $1 billion in additional revenue.