A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their pharmacy options. The findings, reported by the Wall Street Journal, followed a thorough 32-month investigation in advance of a hearing with executives from leading PBMs.
PBMs serve as intermediaries that manage prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—control approximately 80% of the nation’s prescriptions.
The committee’s report indicates that PBMs often maintain lists of preferred drugs that favor higher-priced brand-name medications over more affordable generic alternatives. One striking example mentioned is the case of Humira, an arthritis treatment costing around $90,000 annually, despite the availability of a biosimilar product priced at half that amount.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs if they chose to fill their prescriptions at local pharmacies rather than through its affiliated mail-order service, which effectively restricted patient choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, highlighting that the six largest PBMs control nearly 95% of all prescriptions in the U.S. The FTC report expressed serious concerns, stating that leading PBMs hold substantial power over Americans’ access to affordable medications. It pointed out that vertically integrated PBMs might prioritize their own businesses, creating conflicts of interest that adversely affect independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen have been “overcharging patients for cancer drugs,” resulting in additional revenues exceeding $1 billion for these companies.