A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while limiting their pharmacy options. The report, which followed a 32-month investigation, is anticipated to be discussed in an upcoming hearing featuring executives from the country’s largest PBMs.
PBMs act as intermediaries for health insurers, managing prescription drug plans and negotiating prices with pharmaceutical companies. They also determine patients’ out-of-pocket costs. The nation’s three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—collectively oversee around 80% of U.S. prescriptions.
According to the committee’s findings, PBMs have developed lists of preferred medications that favor high-priced brand-name drugs over more affordable alternatives. For instance, internal communications from Cigna reportedly discouraged the use of less expensive substitutes for Humira, an arthritis treatment that cost around $90,000 annually, despite the availability of a biosimilar priced at half that amount.
Furthermore, Express Scripts has been found to inform patients that filling prescriptions at local pharmacies would incur higher costs than obtaining a three-month supply through its mail-order pharmacy. This practice restricts patients’ choices regarding which pharmacy to use.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report highlighting that the six largest PBMs control nearly 95% of all prescriptions filled in the United States.
The FTC’s findings raise significant concerns, indicating that dominant PBMs wield considerable influence over patients’ access to affordable medications. The report suggests that this structure leads to conflicts of interest where vertically integrated PBMs may favor their own affiliated businesses, potentially harming independent pharmacies and driving up prescription drug prices.
FTC Chair Lina M. Khan emphasized that these intermediaries are contributing to excessive charges for cancer medications, resulting in over $1 billion in additional revenues.