A recent report from the House Committee on Oversight and Accountability alleges that pharmacy-benefit managers (PBMs) are pushing patients towards higher-cost medications and restricting access to certain pharmacies. This report follows a 32-month investigation and is set to play a significant role in an upcoming hearing featuring executives from major PBM companies.
PBMs function as intermediaries between health insurers and prescription drug manufacturers, negotiating drug prices and determining patients’ out-of-pocket costs. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark from CVS Health—control about 80% of all prescriptions in the United States.
According to the committee’s findings, PBMs often favor more expensive branded drugs over less costly alternatives in their preferred drug lists. An example highlighted in the report involves emails from Cigna staff discouraging the use of cheaper substitutes for Humira, a medication for arthritis costing around $90,000 annually, even though a biosimilar was available for half that price.
Additionally, the investigation revealed that Express Scripts informed patients that filling prescriptions at local pharmacies would likely cost them more than obtaining a three-month supply from their affiliated mail-order service, which effectively limits patients’ pharmacy options.
This report echoes similar findings from the U.S. Federal Trade Commission (FTC), which recently noted that the significant concentration of PBMs allows the six largest to oversee nearly 95% of all prescriptions filled within the country. The FTC’s interim report expressed concerns regarding the substantial power PBMs wield over prescription drug access and affordability.
FTC Chair Lina M. Khan remarked that the data suggests these intermediaries may be overcharging patients, particularly for cancer medications, resulting in an excess revenue exceeding $1 billion.