A recent report from the House Committee on Oversight and Accountability reveals that pharmacy benefit managers (PBMs) are directing patients toward more expensive medications while restricting their pharmacy options. This report follows a comprehensive 32-month investigation by the committee, which precedes a hearing involving leaders from the largest PBMs in the country.
PBMs serve 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—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of U.S. prescriptions.
The findings suggest that PBMs have established preferred drug lists that favor higher-cost brand-name drugs over more affordable alternatives. For instance, the report highlights communications from Cigna urging staff to promote the use of Humira, a high-cost treatment for arthritis priced at $90,000 annually, despite the availability of a biosimilar at half the cost.
The committee’s report also noted instances where Express Scripts informed patients that they would incur higher costs at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order pharmacy, thereby limiting patient choices in pharmacy selections.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that increasing consolidation among PBMs has allowed the six largest firms to manage nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern over the significant power held by leading PBMs over Americans’ access to affordable medications, stating that the vertically integrated nature of these organizations could create conflicts of interest, potentially disadvantaging independent pharmacies and inflating drug costs.
FTC Chair Lina M. Khan emphasized that the findings illustrate how PBMs are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue for these middlemen.