A new report by the House Committee on Oversight and Accountability alleges that pharmacy-benefit managers (PBMs) are promoting higher-cost medications and restricting patients’ pharmacy options. This report, viewed by the Wall Street Journal, follows an extensive 32-month investigation by the committee in advance of a hearing featuring executives from the country’s leading PBMs.
PBMs serve as intermediaries that manage prescription drug plans for health insurers, negotiating pricing with pharmaceutical companies while also 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—collectively handle around 80% of prescriptions nationwide.
The committee’s findings indicate that PBMs maintain lists of preferred medications that favor costly brand-name drugs over more affordable alternatives. One notable example cited is Humira, a treatment for arthritis and autoimmune disorders, which had a steep annual cost of $90,000 at the time, despite available biosimilars priced at approximately half that amount.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs for filling prescriptions at local pharmacies compared to obtaining a three-month supply through its own mail-order service, consequently limiting patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, highlighting that the growing vertical integration among PBMs has allowed the six largest managers to oversee nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern over the significant power these leading PBMs hold over Americans’ access to affordable prescription medications. The report warned of potential conflicts of interest, as vertically integrated PBMs may favor their own affiliated services, disadvantaging independent pharmacies and driving up drug prices.
FTC Chair Lina M. Khan emphasized that these findings illustrate how middlemen are effectively overcharging patients for cancer treatments, generating additional revenues exceeding $1 billion.