A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications and restricting their options for filling prescriptions.
The findings came after a 32-month investigation by the committee, which is set to hold a hearing involving executives from the largest PBMs in the country. These managers act as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket expenses.
The report indicates that the top three PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—control around 80% of prescription medications in the U.S. The committee discovered that these PBMs have formulated lists of preferred drugs that favor higher-priced brand-name products over more affordable generic alternatives.
For instance, the report mentions internal communications from Cigna that discouraged the use of cheaper substitutes for Humira, a drug for arthritis and other autoimmune conditions, which was priced at $90,000 annually despite the availability of a biosimilar for approximately half that cost.
The committee also highlighted instances where Express Scripts informed patients that they would incur higher costs for filling prescriptions at local pharmacies compared to obtaining a three-month supply through its mail-order service. This practice effectively restricts patient choices regarding where to fill their prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a related report, asserting that increased vertical integration among PBMs has allowed the six largest providers to handle nearly 95% of all prescriptions in the U.S.
The FTC’s findings raised concerns about the significant power that leading PBMs wield over Americans’ access to and affordability of prescription medications. It warned that this situation creates a conflict of interest, as vertically integrated PBMs may prefer their own affiliated businesses, potentially disadvantaging independent pharmacies and driving up drug costs.
FTC Chair Lina M. Khan noted that these middlemen are reportedly “overcharging patients for cancer drugs,” resulting in additional profits exceeding $1 billion.