A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting their options for where to obtain these drugs. This report follows a 32-month investigation and comes ahead of a hearing featuring executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans on behalf of health insurers, negotiating drug prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs in the U.S. — Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark — handle around 80% of the nation’s prescriptions.
According to the committee’s findings, these PBMs have compiled preferred drug lists that favor pricier name-brand medications over less expensive alternatives. For instance, emails referenced in the report from Cigna’s staff discouraged prescribing cheaper options for Humira, a medication for arthritis and other autoimmune conditions which costs approximately $90,000 annually, despite the availability of a biosimilar for about half that price.
The committee also highlighted that Express Scripts informed patients they would incur higher costs filling prescriptions at local pharmacies compared to obtaining a three-month supply through their mail-order service, thereby limiting patients’ pharmacy options.
Additionally, a recent report from the U.S. Federal Trade Commission (FTC) indicated that increased integration and consolidation have allowed the largest six PBMs to manage nearly 95% of prescriptions filled in the United States. The FTC expressed concerns that leading PBMs wield significant influence over Americans’ access to affordable medications, suggesting a conflict of interest where integrated PBMs may favor their businesses over unaffiliated pharmacies, subsequently driving up costs.
FTC Chair Lina M. Khan noted that these findings indicate that PBMs are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.