A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications and restricting their pharmacy choices. This follows a comprehensive 32-month investigation by the committee ahead of a hearing involving executives from the largest PBM companies.
PBMs serve as intermediaries in managing prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—together manage nearly 80% of all U.S. prescriptions.
The report highlights that PBMs have created preferred drug lists featuring higher-priced brand-name drugs over less expensive alternatives. An example cited in the report involves emails from Cigna, which discouraged the use of cheaper alternatives to Humira, a treatment for autoimmune conditions that costs up to $90,000 annually, despite the availability of a biosimilar at half that price.
The committee’s findings also revealed that Express Scripts informed patients they would incur higher costs at local pharmacies compared to using its affiliated mail-order services, effectively limiting patients’ pharmacy options.
In a related report published earlier by the U.S. Federal Trade Commission (FTC), it was noted that the largest six PBMs manage nearly 95% of all prescriptions filled in the country. The FTC expressed concern over the significant power these PBMs wield over Americans’ access to affordable medications. Their findings indicated that vertically integrated PBMs might have conflicts of interest, favoring their own affiliates over independent pharmacies and contributing to higher drug costs.
FTC Chair Lina M. Khan addressed the issues raised, stating that these intermediaries are “overcharging patients for cancer drugs,” thereby generating an additional $1 billion in revenue.