A recent report released by the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting their options for where to obtain these prescriptions. This report follows a 32-month investigation and comes ahead of a hearing involving leaders from the largest PBMs in the country.
PBMs serve as third-party administrators for prescription drug plans offered by health insurers. They engage in negotiations with pharmaceutical companies to determine the payment rates health plans will offer for specific drugs, also establishing the out-of-pocket costs for patients.
The nation’s three major PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of all prescriptions filled in the U.S.
According to the committee’s findings, PBMs have established lists of preferred medications that favor higher-priced brand-name drugs over cheaper generic options. For instance, the report highlights internal communications from Cigna that discouraged the use of more affordable alternatives to Humira, a medication for arthritis and various autoimmune disorders, which had an annual cost of $90,000, despite the availability of a biosimilar priced at half that amount.
Additionally, the committee observed that Express Scripts informed patients that they would incur higher costs by filling a prescription at their neighborhood pharmacy compared to obtaining a three-month supply from its mail-order service. This practice restricts patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report indicating that the top six PBMs now manage nearly 95% of all prescriptions in the country. The FTC expressed concern over the substantial power now held by leading PBMs, which affects American patients’ access to affordable prescriptions. The report warned that the integrated structure of these PBMs often leads to conflicts of interest that disadvantage independent pharmacies while inflating drug prices. FTC Chair Lina M. Khan noted that these middlemen are reportedly overcharging patients for cancer medications, generating over $1 billion in additional revenue.