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 limiting their pharmacy options. This report follows a comprehensive 32-month investigation and precedes an upcoming hearing featuring executives from the country’s leading PBMs.
PBMs serve as third-party administrators for prescription drug plans, negotiating drug prices with pharmaceutical companies and determining out-of-pocket costs for patients. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of prescriptions.
According to the committee’s findings, PBMs have established preferred drug lists that favor costly brand-name medications over more affordable alternatives. The report includes specific instances from Cigna staff emails that recommended avoiding less expensive substitutes for Humira, a treatment for arthritis that has an annual cost of $90,000, despite the availability of biosimilars at half that price.
Additionally, the committee highlighted that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to ordering a three-month supply from its affiliated mail-order services, thereby restricting patients’ pharmacy choices.
A related report from the U.S. Federal Trade Commission noted that increasing consolidation has allowed the six largest PBMs to oversee nearly 95% of U.S. prescriptions. The FTC raised concerns that these powerful PBMs create a marketplace where conflicts of interest can arise, potentially disadvantaging independent pharmacies and driving up drug prices.
FTC Chair Lina M. Khan emphasized that the findings illustrate how these intermediaries are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.