A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients towards higher-priced medications and restricting their pharmacy choices. The findings emerged from a 32-month investigation leading up to a hearing featuring executives from the top PBM companies.
PBMs, which are third-party administrators for prescription drug plans utilized by health insurers, negotiate prices with drug manufacturers and determine patients’ out-of-pocket expenses. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (a CVS Health company)—control around 80% of all prescriptions in the U.S.
According to the committee’s findings, these managers have established preferred drug lists that prioritize higher-priced brand-name drugs over more affordable options. For instance, internal communications from Cigna were referenced, indicating they discouraged the use of less expensive alternatives to Humira, a costly treatment for arthritis that was priced at $90,000 annually, despite the availability of biosimilars at about half that cost.
The committee also uncovered that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to ordering a three-month supply through their affiliated mail-order service, thereby limiting patients’ pharmacy options.
Additionally, the U.S. Federal Trade Commission recently released a report confirming similar concerns, noting that the six largest PBMs control nearly 95% of all prescriptions in the country. The FTC report expressed alarm over the substantial influence that leading PBMs have over Americans’ access to affordable medications. It highlighted that vertically integrated PBMs might favor their own affiliated services, which can compromise independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan remarked that these findings indicate that PBMs are significantly overcharging patients for cancer medications, generating over $1 billion in extra revenue.