A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards higher-priced medications and restricting their access to various pharmacies. This report, which follows a 32-month investigation and has been reviewed by the Wall Street Journal, comes ahead of a hearing featuring executives from the largest PBMs in the nation.
PBMs serve as third-party administrators for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining the out-of-pocket costs patients face. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage around 80% of the country’s prescriptions.
The report indicates that these PBMs have created preferred drug lists that favor costlier brand-name drugs over more affordable alternatives. It highlights instances, such as emails from Cigna staff suggesting patients avoid lower-cost substitutes for Humira, a medication for arthritis and other autoimmune diseases, which costs about $90,000 annually, with at least one biosimilar available for half that amount.
Additionally, the committee found that Express Scripts informed patients they would incur higher costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, effectively narrowing patient pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a related report, stating that increased consolidation in the industry has allowed the six largest PBMs to oversee nearly 95% of all prescriptions filled in the U.S. The FTC’s findings raise concerns about the significant influence PBMs hold over patient access to affordable medications. Their vertically integrated models may create incentives to prioritize their own affiliated businesses, resulting in conflicts of interest and higher prescription drug prices.
FTC Chair Lina M. Khan noted that these middlemen are contributing to inflated costs for cancer drugs, generating an excess of $1 billion in revenue.