A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications and restricting their pharmacy choices. This report, which was shared with the Wall Street Journal, comes after a comprehensive 32-month investigation by the committee, prior to a hearing involving executives from the top PBMs.
PBMs function as third-party administrators for health insurers’ prescription drug plans, negotiating prices with pharmaceutical companies and determining the out-of-pocket costs for patients. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—account for around 80% of prescriptions filled nationwide.
According to the committee’s findings, these managers have developed preferred drug lists that favor higher-priced brand-name drugs over more affordable options. The report highlights emails from Cigna employees that discouraged prescribing cheaper alternatives to Humira, an arthritis treatment costing approximately $90,000 annually, while a biosimilar was available for about half the price.
Furthermore, the committee discovered that Express Scripts informed patients they would incur lower costs when filling prescriptions through its affiliated mail-order pharmacy rather than local pharmacies. This practice limits patient choice regarding pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) published a similar report, noting that increased vertical integration has led the six largest PBMs to oversee nearly 95% of all prescriptions filled in the country. The findings raised concerns about the significant power these PBMs have over the affordability and accessibility of prescription medications for Americans. The FTC stated that the structure of these PBMs often results in conflicts of interest, giving them the incentive to prefer their own businesses, thereby disadvantaging independent pharmacies and raising drug costs.
FTC Chair Lina M. Khan emphasized that these middlemen have been “overcharging patients for cancer drugs,” generating excess revenue exceeding $1 billion.