A recent report from the House Committee on Oversight and Accountability indicates that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while also restricting pharmacy options. The findings emerged from a comprehensive 32-month investigation by the committee, which precedes an upcoming hearing featuring executives from the largest PBMs in the nation.
PBMs act as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with drug manufacturers and determining the out-of-pocket costs for patients. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—control roughly 80% of prescription drugs in the United States.
The report highlights that PBMs have developed preferred drug lists that frequently favor higher-priced brand-name medications over more affordable alternatives. For instance, it references internal communications from Cigna that discouraged the use of less costly options for Humira, a medication for arthritis and autoimmune conditions that previously cost around $90,000 annually, while a biosimilar was available for about half that price.
Additionally, the committee’s findings reveal that Express Scripts informed patients they would incur higher costs at local pharmacies compared to purchasing a three-month supply from their affiliated mail-order service, thus limiting consumer choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a related report, stating that heightened vertical integration and concentration allow the six largest PBMs to manage nearly 95% of all prescriptions in the country. The FTC’s findings raised concerns about the considerable influence PBMs have on affordability and accessibility of prescription drugs for Americans. They highlighted that vertically integrated PBMs seem to prioritize their own affiliated services, creating conflicts of interest that could disadvantage independent pharmacies and elevate drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen appear to be overcharging patients for cancer medications, contributing to an excess revenue of more than $1 billion.