Pharmacy-benefit managers (PBMs) are allegedly directing patients towards higher-cost medications while restricting their pharmacy options, according to a recent report from the House Committee on Oversight and Accountability.
The committee’s findings emerged from a lengthy 32-month investigation and coincides with an upcoming hearing featuring executives from the largest PBM firms in the United States.
PBMs serve as intermediaries for health insurers, overseeing prescription drug plans. They negotiate prices with pharmaceutical companies and determine patient out-of-pocket costs. The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—are responsible for managing about 80% of U.S. prescriptions.
The report highlighted that PBMs have developed preferred drug lists that favor more expensive brand-name medications over less costly alternatives. Notably, it referenced internal communications from Cigna staff that discouraged the use of lower-priced alternatives to Humira, a medication for arthritis costing around $90,000 annually, despite the availability of similar, more affordable options.
Furthermore, the committee revealed that Express Scripts informed patients they would incur greater expenses when using local pharmacies compared to opting for a three-month supply from their affiliated mail-order service. This practice effectively limits patient choices regarding their pharmacy selections.
A similar report was released earlier this month by the U.S. Federal Trade Commission (FTC), which noted that the increasing consolidation and vertical integration within the industry has led the six largest PBMs to manage nearly 95% of all prescriptions in the U.S.
The FTC’s findings raise concerns about the substantial influence PBMs have on patients’ access to affordable medications. It warned that this consolidation allows vertically integrated PBMs to prioritize their own businesses, thereby disadvantaging independent pharmacies and inflating drug prices. FTC Chair Lina M. Khan emphasized that the current structure allows these middlemen to “overcharge patients for cancer drugs,” generating over $1 billion in additional revenue.