A recent report from the House Committee on Oversight and Accountability has raised concerns about pharmacy-benefit managers (PBMs), alleging that they are steering patients toward higher-priced medications and restricting access to pharmacies. This report comes after a thorough 32-month investigation and precedes a hearing involving executives from major PBMs.
PBMs serve as intermediaries for prescription drug plans, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket costs. The three largest PBMs in the United States—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—are responsible for managing approximately 80% of all prescriptions.
The committee’s findings indicate that PBMs often favor more expensive branded medications in their lists of preferred drugs, neglecting cheaper alternatives. An example highlighted in the report included communication from Cigna employees urging the continued use of Humira, a costly treatment for autoimmune conditions, despite the availability of a biosimilar option at half the price.
Additionally, the report notes that Express Scripts misled patients by indicating that they would pay less by obtaining a three-month supply through its affiliated mail-order pharmacy instead of local pharmacies, effectively limiting patient choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that the top six PBMs control nearly 95% of prescriptions filled in the U.S. The FTC expressed concerns about the power PBMs hold over patients’ access to affordable medications, suggesting that their structure creates conflicts of interest that could disadvantage independent pharmacies and inflate drug costs.
FTC Chair Lina M. Khan emphasized the implications of these findings, stating that these middlemen are contributing to rising costs for cancer drugs, resulting in over $1 billion in added revenue for themselves at patients’ expense.