A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward costlier medications while restricting their choices of pharmacies. The investigation, which spanned 32 months, precedes a hearing involving executives from the largest PBMs in the country.
PBMs serve as intermediaries for health insurers’ prescription drug plans, negotiating prices with pharmaceutical companies and determining patient out-of-pocket costs. The three leading PBMs in the U.S., Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark, collectively manage about 80% of prescriptions.
The committee’s report indicates that PBMs maintain lists of preferred medications that favor higher-priced brand-name drugs over their cheaper counterparts. For instance, emails from Cigna staff discouraged the use of less expensive alternatives to Humira, a medication for arthritis and autoimmune conditions that costs around $90,000 annually, while a biosimilar was available for half that amount.
Furthermore, the committee discovered that Express Scripts advised patients they would incur higher costs at local pharmacies compared to obtaining a three-month supply from its mail-order service, thereby limiting pharmacy options available to patients.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a report that echoed these concerns, noting that the top six PBMs now manage almost 95% of all prescriptions filled in the country. The FTC described the situation as worrisome, stating that these leading PBMs hold substantial control over Americans’ access to affordable medication. This dominance creates an environment where vertically integrated PBMs may favor their affiliated businesses over others, resulting in conflicts of interest and increased drug costs.
FTC Chair Lina M. Khan highlighted that recent findings demonstrate that these intermediaries are overcharging patients for cancer medications, generating over $1 billion in additional revenue.