A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications and restricting their choices of pharmacies. The report follows a 32-month investigation and precedes a hearing involving executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The report indicates that the three largest PBMs—Express Scripts, OptumRx (owned by UnitedHealth Group), and Caremark (part of CVS Health)—control about 80% of U.S. prescriptions.
The committee’s findings show that PBMs often favor higher-priced brand-name drugs over lower-cost alternatives. For example, emails from Cigna staff were highlighted, indicating a discouragement of cheaper substitutes for Humira, a medication priced at around $90,000 annually, when at least one biosimilar option was available for half that cost.
Additionally, Express Scripts informed patients that they would pay more at their local pharmacy than if they obtained a three-month supply through its affiliated mail-order service, effectively limiting patient pharmacy options.
Earlier this month, the U.S. Federal Trade Commission released a related report stating that the largest six PBMs are managing nearly 95% of all U.S. prescriptions. The FTC expressed concern over the power these PBMs wield, which affects Americans’ ability to access and afford their medications. The agency noted that the current system allows integrated PBMs to favor their own businesses, creating conflicts of interest and potentially disadvantaging independent pharmacies while driving up drug costs.
FTC Chair Lina M. Khan commented on the findings, stating that these middlemen are significantly overcharging patients for cancer medications, leading to an increase in revenue exceeding $1 billion.