A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards pricier medications while restricting their choices on where to obtain them. This report, which comes after a 32-month investigation, coincides with an upcoming hearing involving leaders from major PBM companies.
PBMs serve as intermediaries between health insurers and drug manufacturers, negotiating prices for medications and establishing out-of-pocket costs for patients. The three largest PBMs in the U.S.—Express Scripts, OptumRx, and CVS Health’s Caremark—control around 80% of all prescriptions.
According to the report, PBMs have been favoring high-cost brand medications on their preferred drug lists rather than suggesting more affordable options. An example includes emails from Cigna staff recommending against lower-priced alternatives to Humira, a drug priced at approximately $90,000 annually, despite the existence of a biosimilar available for about half the cost.
The committee found that Express Scripts informed patients they would incur higher costs when filling prescriptions at local pharmacies compared to obtaining a three-month supply through their mail-order service, ultimately restricting patient pharmacy choices.
Additionally, a report released by the U.S. Federal Trade Commission (FTC) highlighted similar concerns, indicating that the top six PBMs account for nearly 95 percent of U.S. prescriptions. The FTC expressed alarm over the substantial control these PBMs exert over Americans’ access to affordable medications, suggesting that their business practices favor their subsidiaries, which may disadvantage independent pharmacies and lead to increased drug costs.
FTC Chair Lina M. Khan pointed out that these intermediaries could be overcharging patients for critical medications such as those used in cancer treatment, generating excess revenue exceeding $1 billion.