A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are pushing patients towards more expensive medications while restricting their choices for pharmacies. The findings come after a comprehensive 32-month investigation and precede a hearing involving executives from the nation’s largest PBMs.
PBMs act as intermediaries for prescription drug plans on behalf of health insurers. They negotiate drug prices with pharmaceutical companies and determine out-of-pocket expenses for patients. The three leading PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (a division of CVS Health)—collectively manage around 80% of prescriptions in the United States.
The committee’s investigation indicated that PBMs have curated lists of preferred medications that highlight higher-priced brand-name drugs while sidelining more affordable alternatives. Notably, emails from Cigna employees discouraged the use of a lower-cost biosimilar to Humira, a drug for arthritis and autoimmune conditions with an annual cost of $90,000, even though a similar treatment was available for half the price.
Furthermore, it was found that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through their affiliated mail-order facility. This practice restricts patients’ pharmacy options.
Earlier this month, the Federal Trade Commission (FTC) released a comparable report, noting that increased consolidation has allowed the six largest PBMs to oversee nearly 95% of all U.S. prescriptions. The FTC’s report highlighted concerns that these major PBMs wield substantial influence over Americans’ access to affordable medications. This situation fosters a system in which vertically integrated PBMs may favor their affiliated businesses, leading to conflicts of interest and higher drug prices for consumers.
FTC Chair Lina M. Khan emphasized that the report’s findings indicate that these intermediaries are inflating prices for cancer medications, resulting in excess profits of over $1 billion for the PBMs.