A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications and restricting their options for obtaining them. This report follows a 32-month investigation in advance of a hearing that will involve executives from the largest PBMs in the country.
PBMs serve as intermediaries in prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining the out-of-pocket expenses patients face. The three largest PBMs in the U.S. – Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark – control around 80% of all prescriptions.
Findings from the committee indicate that PBMs often compile lists of preferred medications that favor higher-priced brand-name drugs over more affordable alternatives. An example highlighted in the report includes Cigna emails that discouraged the use of cheaper alternatives to Humira, a medication for arthritis that costs $90,000 annually, despite the availability of a biosimilar for half that amount.
Additionally, the investigation revealed that Express Scripts informed patients they would incur higher costs by filling prescriptions at their local pharmacies compared to using their affiliated mail-order service. This practice restricts patients’ choices regarding where to fill their prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report stating that the six largest PBMs now handle nearly 95% of prescriptions filled in the country due to increasing consolidation and vertical integration. The FTC expressed concern over the significant control PBMs have over patients’ access to medications and the escalating costs associated with them.
FTC Chair Lina M. Khan remarked that these findings indicate that PBMs are potentially overcharging patients for cancer medications, generating over $1 billion in extra revenue.