A new report from the House Committee on Oversight and Accountability reveals that pharmacy benefit managers (PBMs) are directing patients toward more expensive medications and restricting their pharmacy options. This findings come after a 32-month investigation, leading up to a hearing that will include executives from the largest PBM companies in the country.
PBMs serve as intermediaries for prescription drug plans with health insurers, negotiating costs with pharmaceutical companies and determining patient out-of-pocket expenses. The top three PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (part of CVS Health)—control around 80% of the prescriptions filled in the U.S.
The report highlights a troubling trend where PBMs have been creating lists favoring higher-priced brand-name drugs over more affordable alternatives. One cited instance involved Cigna staff discouraging the use of cheaper alternatives to Humira, a drug for arthritis and other autoimmune conditions costing $90,000 annually, despite a biosimilar being available for about half that price.
Furthermore, the committee found that Express Scripts informed patients they would incur higher costs by using their local pharmacy compared to obtaining a three-month supply through their mail-order service, effectively limiting patient choices in pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, emphasizing that increased consolidation among the six largest PBMs allows them to control nearly 95% of U.S. prescriptions. The FTC expressed concerns that these dominant PBMs exert considerable power over American access to affordable medication, creating conflicts of interest that may disadvantage independent pharmacies and inflate drug costs.
FTC Chair Lina M. Khan highlighted that these middlemen are reportedly overcharging patients for cancer medications, generating an additional $1 billion in revenue.