A new report from the House Committee on Oversight and Accountability alleges that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications and restricting their pharmacy options. The findings follow a 32-month investigation by the committee and precede a hearing that features executives from the country’s largest PBMs.
PBMs serve as intermediaries for prescription drug plans administered by health insurers, negotiating prices with pharmaceutical companies on behalf of health plans. They also determine patients’ out-of-pocket expenses. The three largest PBMs in the U.S. — Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark — manage around 80% of all U.S. prescriptions.
According to the report, PBMs have established preferred drug lists that favor higher-priced brand-name drugs instead of more affordable alternatives. An example cited in the report involves emails from Cigna employees, which suggested avoiding cheaper substitutes for Humira, a medication prescribed for arthritis and other autoimmune disorders, priced at $90,000 annually, despite the availability of a biosimilar costing half as much.
The committee’s investigation also uncovered that Express Scripts advised patients they would face higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order pharmacy, thereby restricting patients’ pharmacy choices.
A separate interim report from the U.S. Federal Trade Commission (FTC) noted that increasing vertical integration among PBMs has allowed the six largest companies to oversee nearly 95% of all U.S. prescriptions. This concentration raises concerns about PBMs’ significant influence on Americans’ access to and affordability of prescription drugs, potentially creating conflicts of interest that may disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan highlighted that these intermediaries are “overcharging patients for cancer drugs,” generating additional revenue surpassing $1 billion.