A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting their choice of pharmacies. This report follows a 32-month investigation and precedes a committee hearing featuring top executives from major PBM companies.
PBMs, which serve as intermediaries that manage prescription drug plans for health insurers, negotiate prices with pharmaceutical companies and also determine patient out-of-pocket costs. The three largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—currently oversee about 80% of all prescriptions.
According to the committee’s findings, these managers have established preferred drug lists that favor pricier brand-name medications over lower-cost alternatives. For instance, emails from Cigna staff reportedly discouraged the use of cheaper substitutes for Humira, which treats arthritis and certain autoimmune disorders and has a steep annual cost of around $90,000, even though at least one equivalent biosimilar was available for half the price.
Furthermore, the report reveals that Express Scripts advised patients that filling prescriptions at local pharmacies would cost them more compared to obtaining a three-month supply from its affiliated mail-order service, thus limiting pharmacy options for patients.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a report indicating that increased vertical integration among PBMs has allowed six major players to oversee nearly 95% of prescriptions filled in the country. The FTC expressed concern that the leading PBMs possess considerable influence over patients’ access to affordable medications. Their structure may create conflicts of interest, as integrated PBMs could favor their own services at the expense of independent pharmacies, resulting in higher drug prices.
FTC Chair Lina M. Khan highlighted that these middlemen are “overcharging patients for cancer drugs,” which generates over $1 billion in additional revenue for them.