A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications and restricting their choice of pharmacies. This report, which precedes an upcoming hearing featuring executives from the nation’s largest PBMs, stems from a 32-month investigation.
PBMs play a critical role as third-party administrators of prescription drug plans for health insurers, negotiating prices with pharmaceutical companies on behalf of health plans and determining out-of-pocket costs for patients. The three largest PBMs in the U.S.—Express Scripts, OptumRx of UnitedHealth Group, and CVS Health’s Caremark—control nearly 80% of all prescriptions.
According to the committee, these managers have compiled lists of preferred medications that often highlight higher-priced brand name drugs over less expensive alternatives. The report references communications from Cigna employees who discouraged using more affordable alternatives to Humira, an arthritis and autoimmune disease treatment that previously cost around $90,000 annually, despite a biosimilar option being available for approximately half that price.
The report also criticizes Express Scripts for informing patients that filling a prescription at a local pharmacy would result in higher costs compared to ordering a three-month supply through its mail-order service, effectively limiting patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that increased vertical integration has allowed the six largest PBMs to control nearly 95% of all prescriptions filled in the country. The FTC’s findings suggest a troubling scenario where leading PBMs wield considerable influence over patients’ access to and affordability of prescription drugs, which may lead to conflicts of interest favoring their own affiliated businesses.
FTC Chair Lina M. Khan highlighted that these practices have led to patients being overcharged for cancer medications, generating over $1 billion in additional revenue for these intermediaries.