A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting their options for where to obtain them.
The report, which the Wall Street Journal reviewed, follows a 32-month investigation and comes ahead of a hearing featuring executives from the largest PBMs in the country. PBMs serve as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining the out-of-pocket costs for patients.
The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—collectively manage about 80% of prescriptions filled in the country. According to the committee’s findings, these managers have prioritized lists of preferred medications that often highlight higher-priced brand-name drugs over more affordable options.
The report includes instances where Cigna employees discouraged the use of cheaper alternatives to Humira, a high-cost treatment for autoimmune conditions priced at approximately $90,000 annually, despite the existence of biosimilars available for half that price.
Additionally, the committee discovered that Express Scripts advised patients that filling a prescription locally would cost them more than obtaining a three-month supply from its affiliated mail-order pharmacy, effectively limiting patient choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that increased consolidation has allowed the six largest PBMs to oversee nearly 95% of all U.S. prescriptions. The FTC highlighted the concerning trend, noting that the dominant PBMs wield considerable influence over the affordability and accessibility of prescription drugs for Americans. It also pointed to potential conflicts of interest arising from vertically integrated PBMs that favor their own operations, potentially harming independent pharmacies and driving up drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen are “overcharging patients for cancer drugs,” resulting in additional revenues exceeding $1 billion.