A recent report from the House Committee on Oversight and Accountability indicates that pharmacy-benefit managers (PBMs) are directing patients towards pricier medications and restricting pharmacy choices. The findings come after a 32-month investigation leading to a hearing involving top executives from the major PBM firms.
PBMs, which act as intermediaries for prescription drug plans on behalf of health insurers, negotiate prices with pharmaceutical companies and determine patient out-of-pocket expenses. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage approximately 80% of prescriptions in the United States.
According to the report, PBMs have been found to create preferred drug lists that prioritize more expensive brand-name drugs over affordable alternatives. For instance, the report highlights communications from Cigna discouraging cheaper substitutes for Humira, a medication costing around $90,000 annually, despite the availability of a biosimilar priced at half that rate.
The investigation also uncovered that Express Scripts informed patients they could pay less for a three-month supply via their mail-order service rather than filling prescriptions at local pharmacies, thereby limiting patient choices.
Earlier this month, the Federal Trade Commission (FTC) released a similar report, noting that increased consolidation has allowed the six largest PBMs to control nearly 95% of all prescription fills in the U.S. The FTC expressed concern that significant power held by PBMs complicates Americans’ access to affordable medications, creating potential conflicts of interest that could inflate drug costs and disadvantage independent pharmacies.
FTC Chair Lina M. Khan emphasized that the findings illustrate how these middlemen are effectively overcharging patients for cancer medications, generating over $1 billion in additional revenue.