A recent report from the House Committee on Oversight and Accountability indicates that pharmacy-benefit managers (PBMs) are guiding patients towards more expensive medications while restricting their choices regarding pharmacies. This report follows a 32-month investigation and comes ahead of a hearing featuring executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining the out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of prescriptions in the United States.
The committee’s findings highlight that these managers have developed preferred drug lists that favor higher-priced brand-name medications over more affordable options. For instance, Cigna employees reportedly discouraged the use of cheaper alternatives to Humira, a costly treatment for arthritis, even though a biosimilar was available at a significantly lower price.
Additionally, Express Scripts advised patients that they would incur higher costs filling a prescription at a local pharmacy compared to obtaining a three-month supply from its affiliated mail-order service, which limits patient access to their desired pharmacy options.
A similar report from the U.S. Federal Trade Commission (FTC) also indicated that escalating vertical integration among PBMs has allowed the six largest firms to manage nearly 95% of all U.S. prescriptions. The FTC expressed concern over the growing influence PBMs hold in determining how Americans access and afford their medications, particularly noting that conflicts of interest may arise when PBMs favor their own associated businesses, potentially disadvantaging independent pharmacies and raising drug prices. FTC Chair Lina M. Khan reported that these middlemen have been overcharging patients for cancer medications, accumulating over $1 billion in additional revenue from these practices.