A recent report from the House Committee on Oversight and Accountability highlights that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications and restricting their access to pharmacies. This report follows a 32-month investigation by the committee prior to a hearing involving executives from some of the largest PBMs in the country.
PBMs serve as third-party administrators for prescription drug plans under health insurance policies, negotiating prices with pharmaceutical companies and determining out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, OptumRx (a division of UnitedHealth Group), and Caremark (owned by CVS Health)—control nearly 80% of prescription medications in the U.S.
The committee’s findings indicate that PBMs curate lists of preferred drugs that prioritize higher-priced brand-name medications over their cheaper alternatives. For instance, emails from Cigna employees suggest discouraging the use of less expensive options for Humira, a treatment for arthritis and other autoimmune disorders that costs around $90,000 annually, despite the availability of a biosimilar at approximately half that price.
Additionally, the investigation revealed that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service. This practice limits the pharmacy options available to patients.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, noting that increased vertical integration among PBMs has allowed the six largest managers to oversee nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern over the substantial influence PBMs now wield over Americans’ access to affordable prescription medications. This situation raises potential conflicts of interest as vertically integrated PBMs may favor their own affiliated businesses, potentially harming independent pharmacies and driving up prescription drug prices.
FTC Chair Lina M. Khan emphasized that the findings reveal that these intermediaries are overcharging patients for treatments, particularly cancer drugs, accumulating excess revenue exceeding $1 billion.