A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications and restricting their choices regarding where to obtain prescriptions.
The committee’s examination, which spans over 32 months, precedes a hearing involving executives from the largest PBMs. According to the report, PBMs, which act as intermediaries between drug manufacturers and health insurers, primarily dictate the prices health plans will pay for various medications and establish the out-of-pocket costs for patients.
The major PBMs—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—collectively manage about 80% of U.S. prescriptions. The committee found that these managers have developed lists of preferred drugs, often favoring higher-priced brand-name medications over less expensive alternatives.
An example cited in the report involves staff at Cigna discouraging the use of cheaper substitutes for Humira, an arthritis treatment costing around $90,000 annually, even when a biosimilar was available at half the price.
Moreover, the committee highlighted instances where Express Scripts informed patients that filling prescriptions locally would be costlier than opting for a three-month supply through their affiliated mail-order service, effectively limiting patients’ pharmacy options.
Earlier this month, the U.S. Federal Trade Commission released a similar report, indicating that the six largest PBMs control nearly 95% of all prescriptions in the U.S. The FTC expressed concern about the considerable power these PBMs hold over Americans’ access to affordable medications, which can lead to conflicts of interest favoring their own businesses at the expense of independent pharmacies and increase drug costs for consumers.
FTC Chair Lina M. Khan stated that the findings illustrate how these middlemen are significantly overcharging patients for cancer drugs, resulting in over $1 billion in additional revenue for them.