A recent report from the House Committee on Oversight and Accountability reveals that pharmacy benefit managers (PBMs) are directing patients toward more expensive medications while limiting their pharmacy choices. This report follows a 32-month investigation in preparation for a hearing with executives from major PBMs.
PBMs act as intermediaries for health insurers, negotiating drug prices and establishing patient out-of-pocket costs. The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—control around 80% of prescriptions in the country.
The committee’s findings indicate that PBMs have created preferred drug lists that often feature higher-priced brand-name medications over lower-cost options. For instance, emails from Cigna staff suggested avoiding cheaper alternatives to Humira, an expensive treatment for autoimmune conditions that was priced at $90,000 annually, despite the availability of a biosimilar at half that cost.
Additionally, the report highlights a practice by Express Scripts, which informed patients that filling a prescription at their local pharmacy would be more expensive than obtaining a three-month supply from their affiliated mail-order service, thereby restricting patient choices.
This aligns with a recent Federal Trade Commission (FTC) report emphasizing that the six largest PBMs manage nearly 95% of prescriptions in the U.S., raising concerns about their growing power over drug access and affordability. The FTC cautioned that this vertical integration and concentration of PBMs could lead to conflicts of interest that harm unaffiliated pharmacies and inflate prescription drug prices. FTC Chair Lina M. Khan noted that these middlemen could be overcharging patients for cancer medications, generating over $1 billion in additional revenue.