Feds expand probe into PBMs, including Optum Rx

The House Committee on Oversight and Government Reform said last week that it’s expanding its investigation into the role of pharmacy benefit managers by seeking information about how they use foreign headquartered group purchasing organizations, claiming that some evade transparency and oversight in the United States.

Committee Chairman James Comer, R-KY, sent letters to the CEOs of Optum Rx and the Cigma Group, seeking documents and information about the PBMs’ group purchasing organizations that are headquartered overseas.

“The Committee is investigating whether Cigna Group’s Evernorth Health Services, the parent company of Express Scripts, uses its foreign headquartered group purchasing organization (GPO) – Ascent Health Services, Inc. (Ascent) which is headquartered in Switzerland – to evade transparency and oversight in the United States,” said Comer in a statement. “The Committee requests documents and communications regarding the creation and role of Ascent.”

WHAT’S THE IMPACT

In July 2024, the House Oversight Committee released a report detailing how PBMs have used their position as middlemen to enact anticompetitive policies and protect their bottom line.

The report also highlighted how GPOs create another layer of pricing opacity and complexity, which appeared especially true for GPOs headquartered overseas, as these entities may be used to retain additional revenue and fees, and to sidestep U.S. legislative and regulatory reforms. 

Emisar Pharma was created by United Health Group’s Optum Rx in 2021 and is headquartered in Ireland. Ascent was created by Cigna Group’s Express Scripts in 2019 and is headquartered in Switzerland. 

“The Committee is investigating whether UnitedHealth Group’s Optum Rx, uses its foreign headquartered group purchasing organization (GPO) – Emisar Pharma Services, LLC (Emisar Pharma) headquartered in Ireland – to evade transparency and oversight in the United States,” wrote Comer in the letter to Optum Rx.

THE LARGER TREND

The American Medical Association released data last year showing that the four largest pharmacy benefit managers in the country control roughly 70% of the national market.

The analysis, based on 2022 data on commercial and Medicare Part D prescription drug plan (PDP) enrollees, also found a high prevalence of vertical integration of PBMs with health insurance companies.

CVS Health is the largest PBM (with a 21.3% market share), followed by OptumRx (20.8%), Express Scripts (17.1%) and Prime Therapeutics (10.3%).