A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are funneling patients toward more expensive medications while restricting their options for obtaining these prescriptions. This report follows a 32-month investigation by the committee, which is preparing for a hearing on PBMs involving executives from the largest management firms in the U.S.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating costs with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—control approximately 80% of prescriptions filled in the United States.
According to the findings, PBMs have developed preferred drug lists that favor costlier brand-name medications over more affordable alternatives. For instance, the report references internal communications from Cigna that recommended avoiding cheaper alternatives to Humira, an arthritis treatment priced at $90,000 annually, even though a biosimilar was available at half that cost.
The report also indicated that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its own mail-order service, thereby restricting patient choice in pharmacy selection.
Additionally, the U.S. Federal Trade Commission (FTC) released a similar report earlier this month, noting that the six largest PBMs manage close to 95% of U.S. prescriptions. The FTC expressed concerns over the considerable power PBMs wield over patients’ access to and affordability of medications, suggesting that conflicts of interest arise when vertically integrated PBMs prioritize their affiliated businesses. FTC Chair Lina M. Khan emphasized that these middlemen are contributing to higher prices for cancer drugs, benefiting from over $1 billion in revenue from such practices.