A recent report from the House Committee on Oversight and Accountability accuses pharmacy-benefit managers (PBMs) of directing patients toward more costly medications and restricting their options for obtaining prescriptions. The findings stem from a 32-month investigation, which precedes an upcoming hearing featuring executives from the largest PBMs in the country.
PBMs, which function as intermediaries for health insurers regarding prescription drug plans, negotiate prices with pharmaceutical companies and 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 about 80% of prescriptions filled.
The committee’s report indicates that PBMs maintain lists of preferred medications that tend to favor higher-priced brand-name drugs over less expensive alternatives. An example cited in the report highlights internal communications from Cigna that discouraged the use of cheaper options for Humira, an autoimmune treatment priced at around $90,000 annually, despite the existence of a biosimilar available for approximately half that cost.
Additionally, the report notes that Express Scripts informed patients they would face higher costs at local pharmacies compared to purchasing a three-month supply through its affiliated mail-order service, thereby restricting patient choice in pharmacy selection.
Moreover, a recent Federal Trade Commission (FTC) report supported these findings, noting that due to increasing consolidation, the top six PBMs manage nearly 95% of all prescriptions in the U.S. The FTC expressed concern over the significant power these PBMs wield, impacting Americans’ access to affordable medications. The report emphasized that the vertical integration of PBMs can lead to conflicts of interest, potentially disadvantaging independent pharmacies and inflating prescription costs.
FTC Chair Lina M. Khan remarked that these findings reveal that PBMs are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.