A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are driving patients towards more costly medications while restricting where they can obtain them.
The committee’s findings follow a 32-month investigation and precede an upcoming hearing featuring executives from the largest PBMs in the country. PBMs act as third-party administrators of prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and establishing patients’ out-of-pocket expenses.
The report highlights that Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark manage roughly 80% of U.S. prescriptions. It indicates that these PBMs favor higher-priced brand-name drugs over more affordable alternatives, as evidenced by Cigna’s internal communications discouraging alternatives to Humira, a drug priced at $90,000 annually, despite an available biosimilar costing half that amount.
Additionally, the report notes that Express Scripts informed patients that filling prescriptions at local pharmacies would result in higher costs compared to using its affiliated mail-order service, thereby restricting patient choice regarding pharmacy options.
A similar report from the U.S. Federal Trade Commission (FTC) earlier this month corroborates these findings, stating that increased vertical integration among the six largest PBMs enables them to manage nearly 95% of all prescriptions in the U.S. The FTC’s interim report warns that the leading PBMs wield considerable influence over Americans’ access to affordable prescription drugs and create conflicts of interest by favoring their own affiliated businesses, which may disadvantage independent pharmacies and drive up drug costs.
FTC Chair Lina M. Khan emphasized that these middlemen are “overcharging patients for cancer drugs,” resulting in over $1 billion in additional revenue for PBMs.