A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting their choices in pharmacies. The report, accessed by the Wall Street Journal, comes after a 32-month investigation ahead of a hearing involving leaders from the country’s top PBMs.
PBMs act as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and setting out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—account for about 80% of U.S. prescriptions.
According to the committee’s findings, these managers often maintain preferred drug lists that favor pricier brand-name drugs over less expensive alternatives. For instance, internal communications from Cigna revealed discouragement of using cheaper substitutes for Humira, an arthritis treatment costing $90,000 annually, despite a biosimilar being available for around half the price.
Furthermore, the committee discovered that Express Scripts informed patients they would incur higher costs at local pharmacies compared to obtaining a three-month supply through its own mail-order service, which limits patient options.
Earlier this month, the U.S. Federal Trade Commission released a similar report indicating that the top six PBMs control nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern that this concentration endows PBMs with substantial power over access to and affordability of prescription medications, leading to potential conflicts of interest that could inflate drug costs.
FTC Chair Lina M. Khan highlighted that these practices have resulted in patients facing “overcharging for cancer drugs,” generating over $1 billion in additional revenue for the PBMs.