A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their pharmacy options. This report comes after a 32-month investigation, which coincides with an upcoming hearing featuring executives from major PBMs.
PBMs serve as intermediaries between health insurers and pharmaceutical companies, negotiating drug prices and determining patients’ out-of-pocket costs. The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (a division of CVS Health)—control approximately 80% of prescription drug transactions.
According to the report, PBMs have prioritized higher-cost brand-name drugs on their preferred drug lists, often overlooking more affordable alternatives. For instance, it highlights correspondence from Cigna employees that discouraged using lower-priced substitutes for Humira, a medication for arthritis and autoimmune conditions that peaked at $90,000 annually, despite the availability of a biosimilar priced at half that amount.
Additionally, the committee discovered that Express Scripts informed patients that they could save money by using their affiliated mail-order pharmacy, implying that local pharmacies would result in higher out-of-pocket costs. This practice restricts patient choices regarding where to fill prescriptions.
A similar investigation conducted by the U.S. Federal Trade Commission (FTC) earlier this month found that six major PBMs account for nearly 95% of all U.S. prescriptions. The FTC highlighted concerns about the power PBMs hold over the accessibility and affordability of prescription medications, suggesting that their vertical integration may disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan noted that evidence indicates these middlemen are “overcharging patients for cancer drugs,” resulting in excess revenues surpassing $1 billion.