A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications and restricting their access to pharmacies. This information comes after a 32-month investigation by the committee, which preceded a hearing involving executives from major PBM firms.
PBMs serve as third-party administrators for prescription drug plans and negotiate prices with pharmaceutical companies to determine costs for health plans. Additionally, they decide patients’ out-of-pocket expenses for medications. The three largest PBMs in the United States—Express Scripts, OptumRx (a UnitedHealth Group subsidiary), and Caremark (part of CVS Health)—handle around 80% of all prescriptions in the country.
The committee’s findings indicate that PBMs have developed lists of preferred medications that favor higher-priced brand-name drugs over lower-cost alternatives. Emails from Cigna staff, referenced in the report, discourage the use of cheaper options for medications like Humira, which costs approximately $90,000 annually, despite the existence of biosimilars priced at half that amount.
The investigation also showed that Express Scripts informed patients that filling prescriptions at local pharmacies could lead to higher costs compared to obtaining a three-month supply from their affiliated mail-order service, thereby restricting patients’ pharmacy choices.
Earlier this month, the Federal Trade Commission (FTC) released a similar report stating that the top six PBMs manage nearly 95% of all prescriptions in the U.S., raising alarms about their significant influence over the accessibility and affordability of prescription drugs. The FTC emphasized that this concentration allows PBMs to create conflicts of interest that could disadvantage independent pharmacies and elevate drug prices.
FTC Chair Lina M. Khan highlighted that these middlemen are exacerbating costs for patients, particularly for cancer treatments, leading to an excess of over $1 billion in additional revenue for themselves.