A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their access to other options. This report is the result of a 32-month investigation and precedes a hearing featuring executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs in the United States—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (under CVS Health)—control about 80% of prescriptions filled nationwide.
The committee’s findings indicate that these PBMs have developed lists of preferred medications that prioritize higher-priced brand-name drugs over less expensive alternatives. For instance, emails from Cigna staff referenced in the report advised against using lower-cost alternatives to Humira, a medication for arthritis treated at approximately $90,000 annually, despite the availability of a biosimilar at half that price.
Furthermore, the committee reported that Express Scripts informed patients they would incur higher costs by using local pharmacies instead of its own mail-order service for a three-month supply, thereby limiting patients’ pharmacy choices.
An earlier report from the U.S. Federal Trade Commission (FTC) echoed these concerns, revealing that increased vertical integration has allowed the six largest PBMs to control nearly 95% of all prescriptions in the U.S. The FTC described the current situation as alarming, stating that leading PBMs hold considerable power over Americans’ access to affordable medications. They also highlighted the potential conflicts of interest arising from PBMs favoring their affiliated businesses, which can lead to higher drug costs and negatively affect independent pharmacies.
According to FTC Chair Lina M. Khan, these findings indicate that PBMs may be overcharging patients for essential medications, particularly cancer drugs, resulting in excess revenue exceeding $1 billion.