A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients to higher-cost medications while restricting their access to more affordable alternatives.
This report, which followed a 32-month investigation, comes ahead of a hearing featuring executives from some of the largest PBMs in the nation. PBMs serve as third-party administrators for prescription drug plans provided by health insurers, negotiating prices with pharmaceutical companies and setting the out-of-pocket expenses for patients.
The top three PBMs in the United States—Express Scripts, OptumRx (a division of UnitedHealth Group), and CVS Health’s Caremark—control around 80% of all prescriptions filled in the country.
According to the report, these PBMs have constructed lists of preferred medications that prioritize higher-priced brand-name drugs over less expensive alternatives. An example highlighted involves Cigna, which discouraged the use of a cheaper alternative to Humira, an arthritis treatment that was priced at $90,000 annually, despite a more affordable biosimilar being available.
Additionally, the committee found that Express Scripts informed patients they would pay more to fill a prescription at local pharmacies compared to using its affiliated mail-order service, thereby limiting patient pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission released a similar report indicating that the concentration and vertical integration of the six largest PBMs enable them to manage nearly 95% of all prescriptions in the U.S. The FTC reported that these leading PBMs hold significant power over patients’ access to and affordability of prescription medications, potentially creating conflicts of interest that harm non-affiliated pharmacies and inflate drug costs.
FTC Chair Lina M. Khan noted that these findings suggest that these intermediaries are overcharging patients for cancer medications, resulting in over $1 billion in additional revenue.