A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications while restricting their pharmacy options. The findings, which emerged after a 32-month investigation, preceded a committee hearing that involved executives from the largest PBMs in the United States.
PBMs serve as third-party administrators for prescription drug plans linked to health insurers, negotiating drug prices and determining out-of-pocket costs for patients. The report, reviewed by the Wall Street Journal, highlights that Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health collectively manage around 80% of prescriptions across the country.
One key takeaway from the committee’s findings is that PBMs maintain lists of preferred drugs that often favor more expensive brand-name medications over cheaper alternatives. For instance, the report noted that emails from Cigna discouraged choosing less costly options for Humira, a treatment for arthritis and autoimmune disorders priced at $90,000 annually, even though a biosimilar was available at half that cost.
Additionally, Express Scripts reportedly informed patients that they would incur higher costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, thus limiting patient choices in pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission released a similar report indicating that the top six PBMs control nearly 95% of all U.S. prescriptions, raising concerns about their overwhelming influence on drug accessibility and affordability for Americans. The FTC emphasized that the leading PBMs exert significant power, potentially favoring their own businesses and disadvantaging independent pharmacies, which can lead to higher drug costs for consumers. FTC Chair Lina M. Khan stated that these middlemen are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue for themselves.