A new report from the House Committee on Oversight and Accountability suggests that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their choices regarding where to obtain them. This findings follow a 32-month investigation and precede an upcoming hearing with leaders from the largest PBMs in the U.S.
PBMs serve as intermediaries for health insurers, managing prescription drug plans and negotiating prices with pharmaceutical companies. They also establish the out-of-pocket expenses patients face. The report highlights that the three largest PBMs—Express Scripts, OptumRx, and CVS Health’s Caremark—control around 80% of U.S. prescriptions.
According to the committee’s findings, PBMs have created lists favoring higher-priced brand-name medications over more affordable alternatives. For instance, the report mentions internal communications from Cigna that discouraged using cheaper options to Humira, a medication for arthritis and other autoimmune disorders, which costs $90,000 annually, despite the existence of a biosimilar that is priced at half that amount.
Additionally, the committee noted that Express Scripts informed patients they would incur higher costs at local pharmacies compared to ordering a three-month supply from their affiliated mail-order service, which restricted patient choices regarding their pharmacies.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a related report indicating that the six biggest PBMs now manage about 95% of all prescriptions in the nation due to increasing vertical integration and market concentration. The FTC warned that this trend threatens patients’ access to affordable medications, as these PBMs may prioritize their own affiliated businesses over others, generating conflicts of interest that can drive up costs.
FTC Chair Lina M. Khan emphasized that these findings reveal how PBMs are potentially overcharging patients for crucial medications like cancer drugs, resulting in over $1 billion in excess revenue for these middlemen.