A new report by the House Committee on Oversight and Accountability reveals that pharmacy benefit managers (PBMs) are directing patients toward more expensive medications and restricting their options for filling prescriptions. This report follows a 32-month investigation and comes ahead of a scheduled hearing with executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans provided by health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs—Express Scripts, OptumRx, and CVS Caremark—oversee approximately 80% of prescriptions in the U.S.
The committee’s findings highlight concerns that PBMs have established preferred drug lists prioritizing higher-cost brand-name medications over more affordable alternatives. For instance, emails from Cigna staff were cited, showing discouragement of the use of lower-cost alternatives to Humira, a pricey arthritis and autoimmune treatment costing around $90,000 annually, despite the availability of a biosimilar at half the price.
Moreover, the committee discovered that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, effectively limiting patient choices.
The U.S. Federal Trade Commission (FTC) released a similar report earlier this month, indicating that increased concentration within the industry has allowed the six largest PBMs to control nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern over the significant power wielded by PBMs regarding Americans’ access to and affordability of prescription drugs. This situation promotes conflicts of interest, potentially disadvantaging independent pharmacies and driving up drug costs.
FTC Chair Lina M. Khan noted that these middlemen are allegedly overcharging patients for cancer treatments, leading to over $1 billion in additional revenue.