A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their pharmacy options. This conclusion comes after a 32-month investigation leading up to a hearing on PBMs featuring executives from the largest companies in the sector.
PBMs act as intermediaries for prescription drug plans managed by health insurers, negotiating the prices that health plans pay for medications and determining patients’ out-of-pocket expenses. The three primary PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—control approximately 80% of prescriptions filled nationwide.
The committee’s findings indicate that PBMs have developed preferred drug lists that favor higher-priced brand-name medications over less expensive alternatives. The report highlighted instances, including emails from Cigna staff, that discouraged the use of more affordable options for Humira, a medication for arthritis and autoimmune disorders that cost around $90,000 annually, even when a biosimilar was available at half that cost.
Moreover, the committee noted instances where Express Scripts informed patients they would face higher costs filling prescriptions at local pharmacies compared to purchasing a three-month supply from their mail-order service, effectively reducing patients’ pharmacy choices.
Earlier this month, the Federal Trade Commission (FTC) released a parallel report, stating that increasing consolidation among PBMs has allowed the six largest companies to manage nearly 95% of all prescriptions filled in the United States. The FTC expressed concern that leading PBMs now possess significant influence over Americans’ access to affordable medications. This situation fosters conflicts of interest, as vertically integrated PBMs may favor their affiliated businesses over independent pharmacies, potentially raising drug prices.
FTC Chair Lina M. Khan emphasized that the findings suggest these intermediaries are “overcharging patients for cancer drugs,” generating additional revenue exceeding $1 billion.