A recent report from the House Committee on Oversight and Accountability accuses pharmacy benefit managers (PBMs) of directing patients towards more expensive drugs while restricting their options for obtaining medications. This report emerged following a thorough 32-month investigation by the committee in anticipation of a hearing involving leaders from the largest PBMs in the U.S.
PBMs serve as intermediaries for prescription drug plans on behalf of health insurers, negotiating costs with pharmaceutical companies and determining the out-of-pocket expenses for consumers. The three largest PBMs in the country—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Caremark—manage about 80% of all U.S. prescriptions.
The committee’s findings revealed that these PBMs favor higher-priced brand-name medications over more affordable alternatives in their preferred drug lists. An example highlighted in the report involves emails from Cigna, which discouraged the use of cheaper alternatives to Humira, a drug used for arthritis and other autoimmune conditions that cost around $90,000 annually, despite the availability of a biosimilar at half the price.
Additionally, the committee noted that Express Scripts informed patients they would incur higher costs when filling prescriptions at local pharmacies compared to obtaining a three-month supply through its mail-order service, thereby restricting patients’ choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) published a similar report indicating that increased consolidation among PBMs has led these six largest managers to control nearly 95% of all prescriptions filled in the United States. The FTC expressed concern that this concentration grants PBMs significant power over Americans’ access to affordable medications. The report highlighted potential conflicts of interest, as vertically integrated PBMs may favor their own affiliated businesses, disadvantaging independent pharmacies and driving up drug prices.
FTC Chair Lina M. Khan remarked that the findings suggest these middlemen are “overcharging patients for cancer drugs,” resulting in an additional revenue stream exceeding $1 billion for them.