A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are guiding patients towards more expensive medications while limiting their pharmacy choices. This report follows a 32-month investigation and comes ahead of a hearing featuring executives from the largest PBMs in the country.
PBMs are third-party entities that administer prescription drug plans on behalf of health insurers, negotiating pricing with pharmaceutical companies and determining patients’ out-of-pocket costs. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control approximately 80% of prescriptions filled in the United States.
The committee’s findings indicated that PBMs are favoring higher-priced brand-name drugs over cheaper alternatives. Notably, emails from staff at Cigna discouraged the use of more affordable substitutes for Humira, a medication for arthritis and other autoimmune conditions, which had an annual cost of $90,000, despite the availability of biosimilars priced at half that amount.
Moreover, Express Scripts reportedly informed patients that filling prescriptions at their local pharmacies would incur higher costs than obtaining a three-month supply through its affiliated mail-order service, thereby limiting patients’ options for where to fill prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report, noting that the largest PBMs manage nearly 95% of all prescriptions in the U.S. The FTC expressed concern over the significant influence these PBMs hold over patients’ access to affordable medications and pointed out potential conflicts of interest arising from their vertical integration, which may disadvantage independent pharmacies and drive up drug prices.
FTC Chair Lina M. Khan highlighted that the findings indicate PBMs are “overcharging patients for cancer drugs,” resulting in over $1 billion in additional revenue for these intermediaries.