A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards costlier medications while restricting their pharmacy choices. The report follows a comprehensive 32-month investigation leading up to a hearing on PBMs, which included leaders from the largest management firms in the country.
PBMs function as intermediaries between health insurers and pharmaceutical companies, negotiating drug prices and determining patients’ out-of-pocket expenses. The three dominant PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage around 80% of prescriptions in the United States.
According to the committee’s findings, PBMs maintain lists of preferred medications that prioritize expensive brand-name drugs over more affordable alternatives. An example highlighted in the report involves Cigna staff emails that discouraged the use of cheaper options for Humira, a drug for arthritis and autoimmune conditions that cost about $90,000 annually, despite the availability of a biosimilar for around half that price.
Additionally, the report indicated that Express Scripts conveyed to patients that they would face higher costs at local pharmacies in comparison to ordering a three-month supply from their affiliated mail-order pharmacy, thereby limiting patient pharmacy options.
A similar report released by the U.S. Federal Trade Commission (FTC) noted that the top six PBMs control nearly 95% of prescriptions filled across the country due to increased vertical integration and concentration in the market. The FTC expressed concern over the significant influence these PBMs wield over patients’ access to affordable medications, leading to conflicts of interest and potentially higher drug prices.
FTC Chair Lina M. Khan highlighted that these middlemen could be overcharging patients for cancer treatments, resulting in additional revenues exceeding $1 billion.