A recent report from the House Committee on Oversight and Accountability highlights concerns that pharmacy-benefit managers (PBMs) are pushing patients towards more expensive medications while limiting their options for pharmacies. The report follows a 32-month investigation and precedes a hearing featuring executives from the largest managers in the country.
PBMs serve as intermediaries for health insurers’ prescription drug plans, negotiating prices with pharmaceutical firms and determining patient out-of-pocket costs. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of all prescriptions.
The committee’s findings indicate that PBMs curate lists of preferred medications that often favor high-priced brand-name drugs over cheaper alternatives. For instance, emails from Cigna personnel were referenced, revealing discouragement of using less expensive options for Humira, an arthritis treatment costing around $90,000 annually, despite the availability of a biosimilar version at half the price.
Additionally, the report noted that Express Scripts informed patients they would face higher costs at their local pharmacies compared to obtaining a three-month medication supply through its affiliated mail-order service. This practice restricts patient choices regarding pharmacy selections.
A coinciding report from the U.S. Federal Trade Commission (FTC) emphasized that increased consolidation among PBMs has enabled the six largest companies to manage nearly 95% of prescriptions in the U.S. The FTC expressed concern that the leading PBMs wield considerable influence over access to affordable medications. These practices can create conflicts of interest, as vertically integrated PBMs may prioritize their own affiliated operations, potentially disadvantaging independent pharmacies and inflating drug prices.
FTC Chair Lina M. Khan remarked that findings suggest these intermediaries are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue in the process.