According to a recent report from the House Committee on Oversight and Accountability, pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their pharmacy options.
The investigation, which lasted 32 months, led to a report that was reviewed by the Wall Street Journal, just before a congressional hearing that included executives from major PBM companies. PBMs function as intermediaries for prescription drug plans for health insurers, negotiating drug prices with pharmaceutical manufacturers and determining patients’ out-of-pocket costs. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (operated by CVS Health)—control about 80% of prescriptions in the United States.
The committee found that PBMs tend to prioritize higher-priced brand-name drugs on their preferred drug lists instead of promoting cheaper alternatives. For instance, emails revealed that staff at Cigna discouraged the use of biosimilars for Humira, a costly treatment for arthritis and other autoimmune diseases that was priced at $90,000 annually, despite the availability of a biosimilar at half that price.
Moreover, the committee discovered that Express Scripts informed patients they would incur higher costs if they chose to fill their prescriptions at local pharmacies compared to receiving a three-month supply from its own mail-order service, thereby limiting patients’ pharmacy options.
Additionally, the U.S. Federal Trade Commission (FTC) released a similar report, indicating that the increasing consolidation among PBMs has allowed the six largest firms to manage about 95% of all prescriptions filled nationwide. The findings underscore concerns that leading PBMs exert considerable control over Americans’ access to affordable medications. The FTC noted that this vertical integration creates conflicts of interest, favoring affiliated businesses at the expense of independent pharmacies and driving up drug costs. FTC Chair Lina M. Khan stated that these findings indicate patients are being overcharged for cancer medications, generating excess revenue over $1 billion for PBMs.