A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their access to alternatives. The findings of this 32-month investigation come ahead of a hearing featuring executives from the nation’s largest PBMs.
PBMs act as intermediaries for prescription drug plans, negotiating drug prices on behalf of health insurers and setting patient out-of-pocket costs. The three largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—control around 80% of the country’s prescription fills.
The committee’s report highlights that PBMs often promote lists of preferred drugs that favor high-priced brand names over cheaper generic options. For instance, it points to internal communications from Cigna that suggested avoiding cheaper alternatives to Humira, a medication for arthritis and other autoimmune conditions priced at approximately $90,000 annually—despite the availability of a biosimilar costing half that amount.
Additionally, the report indicates that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to getting a three-month supply from their affiliated mail-order service. This practice, according to the committee, limits patient choice regarding pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar interim report, noting that increasing consolidation among the largest PBMs allows them to manage nearly 95% of all U.S. prescriptions. The FTC expressed concern about the significant power PBMs hold over patients’ access to and affordability of medications, citing conflicts of interest that benefit affiliated businesses while disadvantaging independent pharmacies and driving up drug costs.
FTC Chair Lina M. Khan emphasized that these findings reveal how middlemen in the prescription process have been “overcharging patients for cancer drugs,” resulting in excess revenue exceeding $1 billion.