A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards costlier medications and restricting their pharmacy options. The report, which follows a 32-month investigation, will play a significant role in an upcoming hearing involving executives from major PBM firms.
PBMs serve as intermediaries for health insurers in managing prescription drug plans and negotiate prices with pharmaceutical companies. They also determine out-of-pocket expenses for patients. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of all prescriptions filled in the country.
According to the committee’s findings, PBMs have been favoring higher-priced brand-name drugs over more affordable alternatives. For instance, emails from Cigna staff highlighted discouragement against using cheaper options for Humira, a medication for arthritis and other autoimmune disorders priced at $90,000 annually, despite the availability of a biosimilar costing half as much.
The report also indicated that Express Scripts informed patients they would incur greater costs if they filled a prescription at their local pharmacy compared to obtaining a three-month supply through its affiliated mail-order service. This tactic effectively restricts patients’ choices regarding where they can get their medications.
Earlier this month, the Federal Trade Commission (FTC) released a similar report, indicating that the top six PBMs manage nearly 95% of prescriptions in the U.S. The FTC expressed concern over the considerable influence these PBMs have over patients’ access to affordable drugs, suggesting that their integrated operations may lead to conflicts of interest that disadvantage non-affiliated pharmacies and inflate drug prices.
FTC Chair Lina M. Khan stated that the findings reveal how these intermediaries may be overcharging patients for vital medications like cancer drugs, yielding additional revenue exceeding $1 billion.