A new report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients toward higher-cost medications and restricting their pharmacy options. This report, which followed a 32-month investigation, is set to precede a hearing involving executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket expenses for patients. The three biggest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—oversee around 80% of prescriptions in the United States.
The investigation discovered that certain PBMs have established preferred drug lists featuring more expensive brand-name medications over lower-cost alternatives. An example highlighted in the report includes Cigna staff discouraging the use of more affordable substitutes for Humira, which is used to treat arthritis and other autoimmune diseases and costs about $90,000 per year, even though at least one biosimilar was available for half that price.
Additionally, findings showed that Express Scripts informed patients they would incur greater costs if they filled prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service. This practice effectively constrained patients’ choices regarding their pharmacy options.
Earlier this month, the U.S. Federal Trade Commission released a similar interim report, indicating that increased vertical integration has enabled the six largest PBMs to dominate nearly 95% of all prescriptions dispensed in the U.S. The FTC expressed concern over the influence these leading PBMs have on accessibility and affordability of medications, warning that their structure could favor their own businesses at the expense of independent pharmacies, leading to higher drug prices.
FTC Chair Lina M. Khan emphasized that the findings suggest these intermediaries are overcharging patients for cancer medications, generating an extra $1 billion in revenue.