A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting their pharmacy options. This investigation, spanning 32 months, comes ahead of a hearing featuring executives from the largest PBMs in the U.S.
PBMs act as third-party administrators for prescription drug plans, negotiating costs with pharmaceutical companies and influencing the out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—control roughly 80% of all prescriptions in the U.S.
According to the report, PBMs have established lists of preferred medications that favor higher-cost brand-name drugs over more affordable alternatives. For instance, internal communications from Cigna revealed discouragement against using cheaper substitutes for Humira, a drug that previously cost around $90,000 annually, even though a biosimilar was available at half that price.
Additionally, the committee noted that Express Scripts informed patients they would pay more at local pharmacies compared to ordering a three-month supply through its affiliated mail-order service, effectively restricting pharmacy choices.
The findings align with a recent report from the U.S. Federal Trade Commission (FTC), which highlighted that the largest six PBMs now oversee nearly 95% of all prescriptions in the country. The FTC expressed concern over PBMs’ influence on drug accessibility and affordability, reflecting a system that may favor their own affiliates, thus disadvantaging independent pharmacies and increasing costs for patients.
FTC Chair Lina M. Khan stated that the data indicates patients are being overcharged for vital medications, with the PBMs generating over $1 billion in additional profits from this arrangement.