A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications while restricting their access to alternatives.
The investigation, which lasted 32 months and precedes a hearing involving executives from major PBMs, indicates that these third-party administrators play a pivotal role in managing prescription drug plans for health insurers. They negotiate prices with pharmaceutical companies and establish out-of-pocket costs for patients.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control approximately 80% of prescriptions nationwide.
According to the findings, the committee discovered that PBMs maintain lists of preferred medications that often include higher-cost brand-name drugs instead of lower-cost generic options. An example highlighted in the report is an internal communication from Cigna discouraging the use of more affordable alternatives to Humira, which was priced at $90,000 annually, despite the availability of a biosimilar for half that price.
The investigation also revealed that Express Scripts informed patients that they could face higher costs if they filled prescriptions at their local pharmacy instead of using its affiliated mail-order service, effectively limiting patient choice in selecting pharmacies.
A similar report from the U.S. Federal Trade Commission (FTC) corroborated these findings, indicating that the largest six PBMs control nearly 95 percent of all prescriptions filled in the United States. The FTC noted the considerable power these PBMs wield over Americans’ access to and affordability of medications, leading to potential conflicts of interest that may disadvantage independent pharmacies and elevate drug costs.
FTC Chair Lina M. Khan emphasized that these findings illustrate how PBMs may be inflating prices for cancer drugs, resulting in an extra $1 billion in revenue from patients.