A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward higher-priced medications while restricting their options for acquiring them. This report follows a comprehensive 32-month investigation ahead of an upcoming hearing featuring executives from the nation’s leading PBMs.
PBMs serve as third-party administrators for prescription drug plans tied to health insurers, negotiating prices with pharmaceutical companies and determining the out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (affiliated with CVS Health)—collectively handle around 80% of U.S. prescriptions.
The findings indicate that these managers have developed preferred drug lists that favor costly brand-name medications over more affordable alternatives. The report mentions that Cigna, for instance, discouraged the use of less expensive substitutes for Humira, a medication used to treat arthritis that costs $90,000 annually, despite the availability of biosimilars at half the price.
Additionally, it was found that Express Scripts informed patients they would incur higher costs if they filled prescriptions at local pharmacies compared to getting a 90-day supply through its mail-order service, thus limiting patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that vertical integration among PBMs has resulted in the top six PBMs managing nearly 95% of all U.S. prescriptions. The FTC expressed concern over the significant control these PBMs have over Americans’ access to and affordability of prescription drugs, stating that the structure creates conflicts of interest that may disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan highlighted that the findings indicate that these intermediaries are inflating costs for patients, particularly for cancer medications, generating over $1 billion in extra revenue.