A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their options for obtaining them. This finding follows a 32-month investigation by the committee and precedes a hearing that will involve executives from the largest PBM companies in the country.
PBMs act as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with drug manufacturers and determining patient out-of-pocket expenses. The three largest PBMs in the United States—Express Scripts, OptumRx (affiliated with UnitedHealth Group), and CVS Health’s Caremark—handle about 80% of prescriptions across the nation.
The committee’s report indicates that PBMs favor more costly brand-name drugs over less expensive alternatives in their lists of preferred medications. An example highlighted in the report mentions emails from Cigna that discouraged the use of affordable alternatives to Humira, a drug used for treating arthritis and other autoimmune conditions that had a price tag of $90,000 annually. At least one biosimilar was available for half that amount.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to purchasing a three-month supply from their own mail-order service. This practice restricts patient choice regarding pharmacy access.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report, noting that increased vertical integration among the six largest PBMs has enabled them to manage nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern over the significant power these PBMs wield over Americans’ access to affordable prescription drugs, as well as the conflicts of interest arising from their affiliations with particular businesses, which could disadvantage independent pharmacies and further inflate drug prices.
FTC Chair Lina M. Khan stated that the findings illustrate how these intermediaries are overcharging patients, particularly for cancer treatments, leading to additional revenue exceeding $1 billion for these companies.