A recent report from the House Committee on Oversight and Accountability highlights concerns regarding pharmacy-benefit managers (PBMs) allegedly directing patients towards more expensive medications while restricting their pharmacy options.
The report emerged following a 32-month investigation and precedes a hearing featuring executives from the largest PBMs. PBMs operate as third-party administrators for prescription drug plans, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket costs.
The three dominant PBMs in the United States—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—together manage around 80% of prescriptions.
Findings from the committee indicate that these managers often prioritize higher-priced brand-name medications over more affordable alternatives. For instance, the report referenced internal communications from Cigna that discouraged staff from recommending cost-effective substitutes for Humira, a costly treatment for arthritis and autoimmune conditions, despite the availability of a biosimilar option at half the price.
Furthermore, Express Scripts reportedly informed patients that filling prescriptions through their affiliated mail-order pharmacies would be cheaper than doing so at local pharmacies, which limited patients’ choices.
A corresponding report from the U.S. Federal Trade Commission, released earlier this month, noted that the top six PBMs control nearly 95% of all prescriptions dispensed in the U.S. This concentration of power raises significant concerns about patient access to affordable medications. The FTC warned that the current structure allows integrated PBMs to favor their businesses over independent pharmacies, leading to potential conflicts of interest and increased drug costs.
FTC Chair Lina M. Khan stated that these practices could result in patients being overcharged for essential medications, particularly cancer drugs, generating excess revenue for PBMs that exceeds $1 billion.