A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting access to alternatives. The findings emerged from a 32-month investigation, leading up to a hearing featuring executives from the country’s largest PBMs.
PBMs, which serve as third-party administrators for prescription drug plans provided by health insurers, play a vital role in negotiating prices with pharmaceutical companies. They also determine the out-of-pocket expenses incurred by patients.
The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (part of CVS Health)—together manage about 80% of all prescriptions filled in the country.
The committee’s report highlights a concerning trend: these PBMs have established preferred drug lists that favor high-priced brand-name medications over more affordable alternatives. One example mentioned involved emails from Cigna that discouraged prescribing less expensive options for Humira, a drug used to treat arthritis and autoimmune conditions, which had a price tag of $90,000 annually, despite biosimilar versions available for about half that cost.
Furthermore, the investigation revealed that Express Scripts informed patients that they could pay less for a three-month supply of a drug through its affiliated mail-order service compared to local pharmacies, effectively limiting patient choice in selecting pharmacies.
Earlier in the month, the U.S. Federal Trade Commission (FTC) released a similar report, noting that the significant concentration of power within the six largest PBMs allows them to control nearly 95% of prescriptions filled in the United States. The FTC’s findings indicate that these leading PBMs possess considerable influence over the accessibility and affordability of prescription drugs for Americans. This structure raises concerns about potential conflicts of interest, particularly since vertically integrated PBMs may favor their own affiliates, disadvantaging independent pharmacies and contributing to rising prescription drug costs.
FTC Chair Lina M. Khan emphasized the troubling implications of these practices, stating that the middlemen could be overcharging patients for cancer medications, leading to excess revenue exceeding $1 billion.