A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are pushing patients towards more expensive medications while restricting their pharmacy options. The report, which stemmed from a 32-month investigation, coincided with an upcoming hearing on PBMs that will feature executives from the largest managerial firms in the country.
PBMs serve as third-party administrators for prescription drug plans, negotiating prices with pharmaceutical companies on behalf of health insurers and determining the out-of-pocket expenses for patients. The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—handle roughly 80% of all prescriptions filled.
According to the findings detailed in the report, PBMs are favoring high-cost brand-name drugs on their preferred drug lists instead of more affordable alternatives. For instance, the report cites internal Cigna emails that discouraged using lower-cost substitutes for Humira, a treatment that previously cost around $90,000 annually, despite the availability of a biosimilar priced at half that amount.
The committee’s investigation also revealed that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service. This practice was criticized for limiting patients’ choices regarding where to fill their prescriptions.
This report follows a similar investigation by the U.S. Federal Trade Commission (FTC), which noted that the largest six PBMs manage nearly 95% of all prescriptions in the country. The FTC highlighted concerns about the significant power these PBMs have over the affordability and accessibility of prescription drugs for Americans.
FTC Chair Lina M. Khan stated that findings suggest these intermediaries are overcharging patients for cancer medications, resulting in additional revenue exceeding $1 billion.