A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward higher-cost medications while restricting their pharmacy options. The findings stem from a comprehensive 32-month investigation conducted by the committee prior to an upcoming hearing featuring executives from the country’s largest PBMs.
PBMs act as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket costs. The three largest PBMs—Express Scripts, OptumRx (a subsidiary of UnitedHealth Group), and Caremark (part of CVS Health)—control around 80% of all prescriptions in the U.S.
The report highlights that many PBMs maintain preferred drug lists that favor higher-priced branded medications over more affordable alternatives. For instance, emails from Cigna personnel suggested avoiding cheaper options for Humira, an arthritis medication priced at $90,000 annually, despite the availability of a biosimilar at half that cost.
Additionally, the committee found that Express Scripts informed patients they would incur higher costs by opting for local pharmacies compared to using its own mail-order service. This practice limits patient choices regarding where to fill prescriptions.
A similar report released earlier this month by the U.S. Federal Trade Commission (FTC) indicated that the top six PBMs manage nearly 95% of all prescriptions in the U.S., raising concerns about their growing influence. The FTC noted this concentration of power can hinder Americans’ access to affordable medications and create conflicts of interest by favoring integrated businesses, resulting in higher prescription drug prices.
FTC Chair Lina M. Khan expressed concern over the overcharging of patients for cancer medications, which has generated over $1 billion in additional revenue for PBMs.