A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications and restricting their pharmacy options. This report follows a 32-month investigation by the committee and sets the stage for an upcoming hearing featuring executives from the largest PBM companies in the nation.
PBMs serve as third-party administrators for prescription drug plans administered by health insurers, negotiating prices with pharmaceutical companies and establishing patients’ out-of-pocket costs. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage nearly 80% of all prescriptions.
The report indicates that these managers have created preferred drug lists that favor higher-priced brand-name medications over more affordable alternatives. For instance, emails from Cigna employees discouraged the use of cheaper options for Humira, an arthritis treatment priced at $90,000 annually, despite the availability of a biosimilar for around half that cost.
Moreover, the committee discovered that Express Scripts informed patients that filling their prescriptions at a local pharmacy would result in higher costs compared to obtaining a three-month supply from its mail-order pharmacy. This practice limits patients’ choices regarding where to obtain their medications.
In a related finding, the U.S. Federal Trade Commission (FTC) recently released an interim report detailing how increased consolidations have enabled the six largest PBMs to control almost 95% of prescriptions filled in the country. The FTC expressed concern that the leading PBMs wield considerable power over patients’ access to and affordability of prescription drugs. The report also suggests that vertically integrated PBMs may favor their own affiliated services, leading to conflicts of interest that disadvantage independent pharmacies and inflate drug costs.
FTC Chair Lina Khan emphasized that the findings demonstrate how these intermediaries are overcharging patients for cancer medications, resulting in an extra $1 billion in revenue.