A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their pharmacy choices. This report follows a 32-month investigation and comes ahead of a congressional hearing featuring executives from the largest PBMs.
PBMs, which act as intermediaries for prescription drug plans, negotiate pricing with pharmaceutical companies and determine patients’ out-of-pocket costs. The three largest PBMs in the U.S.—Express Scripts, OptumRx, and Caremark—control about 80% of prescriptions.
The committee’s findings highlight that PBMs often promote lists of preferred medications that prioritize high-priced brand-name drugs over more affordable options. An example mentioned in the report involves Cigna, which discouraged the use of less expensive alternatives to Humira, a drug costing around $90,000 annually, despite the presence of a biosimilar available for half that price.
Additionally, the investigation revealed that Express Scripts informed patients they would pay less by acquiring a three-month supply through its mail-order service compared to their local pharmacy, effectively restricting patient choice.
This report coincides with an earlier publication from the U.S. Federal Trade Commission (FTC), which noted that the largest six PBMs administer nearly 95% of all U.S. prescriptions. The FTC expressed concern, stating that leading PBMs hold considerable influence over Americans’ access to affordable medications. The agency highlighted potential conflicts of interest, as vertically integrated PBMs may favor their affiliated businesses, disadvantaging independent pharmacies and driving up drug costs.
FTC Chair Lina M. Khan emphasized that these middlemen are significantly inflating costs for patients, particularly for cancer treatments, netting over $1 billion in additional revenue.