A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward costlier medications and restricting their pharmacy options. This report comes after a thorough 32-month investigation, which precedes a hearing featuring executives from the largest PBMs in the country.
PBMs serve as third-party administrators for prescription drug plans provided by health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket costs. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—collectively manage around 80% of prescriptions in the United States.
The committee’s findings indicate that PBMs maintain lists of preferred medications that favor higher-priced brand-name drugs rather than more affordable alternatives. For instance, emails from Cigna staff discouraged the use of less expensive substitutes for Humira, an arthritis treatment priced at $90,000 annually, despite the availability of a biosimilar option costing half that price.
The report also highlighted that Express Scripts informed patients that they would incur higher costs if they opted to fill a prescription at a local pharmacy compared to obtaining a three-month supply through their affiliated mail-order service. This practice restricts patients’ choices regarding their pharmacy options.
Additionally, a recent report from the U.S. Federal Trade Commission echoed these concerns, stating that increased vertical integration among PBMs has led to the six largest managers overseeing nearly 95% of prescriptions in the U.S. The FTC warned that PBMs possess significant influence over Americans’ access to affordable medications, creating potential conflicts of interest that may disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan noted that these middlemen are allegedly overcharging patients for cancer treatments, generating over $1 billion in additional revenue.