A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are pushing patients towards more expensive medications and limiting their pharmacy options. The findings come after a 32-month investigation and precede a hearing involving top executives from the nation’s largest PBMs.
PBMs act as intermediaries that manage prescription drug plans for health insurance providers, negotiating prices with pharmaceutical companies and determining out-of-pocket expenses for patients. The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control roughly 80% of all U.S. prescriptions.
According to the committee’s report, these managers have established preferred drug lists that favor higher-priced brand-name medications over more affordable alternatives. For instance, emails from Cigna staff reportedly discouraged the use of less expensive substitutes for Humira, an arthritis treatment that cost $90,000 annually, despite a biosimilar being available for about half that price.
Additionally, the report indicates that Express Scripts advised patients that filling prescriptions at local pharmacies would incur higher costs compared to obtaining a three-month supply from its affiliated mail-order service, which restricted patient choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, highlighting that increased vertical integration among PBMs allows the six largest companies to manage nearly 95% of all prescriptions in the U.S. The FTC characterized this trend as troubling, stating that “leading PBMs now exercise significant power over Americans’ access to and affordability of prescription drugs.” The situation raises concerns about conflicts of interest, as PBMs appear incentivized to prioritize their own affiliated businesses, which can disadvantage independent pharmacies and drive up drug prices.
FTC Chair Lina M. Khan emphasized that the findings indicate middlemen are “overcharging patients for cancer drugs,” leading to additional revenues exceeding $1 billion.