A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their pharmacy options.
This report, as reported by the Wall Street Journal, comes after a 32-month investigation by the committee in anticipation of a hearing involving executives from the nation’s largest PBMs. These third-party administrators manage prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket costs for patients.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control roughly 80% of all U.S. prescriptions. The committee’s findings suggest that PBMs are promoting preferred drug lists that highlight higher-priced brand-name drugs instead of more affordable alternatives.
One example cited in the report involves emails from Cigna staff discouraging the use of cheaper substitutes for Humira, which treats arthritis and other autoimmune conditions at a cost of $90,000 annually, despite the availability of biosimilars at half that price.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs if they filled prescriptions at local pharmacies versus obtaining a three-month supply through its affiliated mail-order service, thereby limiting patient choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that increased integration and concentration among PBMs has enabled the six largest to manage nearly 95% of all U.S. prescriptions.
The FTC’s findings raised concerns that leading PBMs significantly influence Americans’ access to affordable medications. The report highlighted that vertically integrated PBMs may favor their own affiliated businesses over unaffiliated pharmacies, leading to higher drug costs. FTC Chair Lina M. Khan stated that these practices result in patients being overcharged for cancer treatments, generating over $1 billion in additional revenue for PBMs.