A new report from the House Committee on Oversight and Accountability indicates that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their choice of pharmacies. This finding follows a 32-month investigation by the committee and comes ahead of a hearing featuring executives from the largest PBMs in the U.S.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and establishing the out-of-pocket expenses that patients incur. Currently, the three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage nearly 80% of prescriptions filled across the nation.
According to the report, these PBMs have developed preferred drug lists that favor higher-priced branded medications over more affordable alternatives. One highlighted instance involves Cigna employees discouraging the use of less expensive substitutes for Humira, a treatment for arthritis that costs around $90,000 annually, despite the presence of a biosimilar costing significantly less.
The committee also discovered that Express Scripts informed patients that they would incur higher costs if they filled prescriptions at local pharmacies as opposed to using its mail-order service. This practice effectively restricts patients’ pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, noting that “increasing vertical integration and concentration” has allowed the six largest PBMs to handle approximately 95% of prescriptions in the U.S. The FTC expressed concern over the significant influence these leading PBMs have over patients’ access to and affordability of medications, suggesting that their operations can lead to conflicts of interest that disadvantage independent pharmacies and elevate drug costs.
FTC Chair Lina M. Khan highlighted that the findings reveal that these intermediaries are “overcharging patients for cancer drugs,” earning an excess of $1 billion in additional revenue.