A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications while restricting their access to options. This report follows a 32-month investigation and comes ahead of a scheduled hearing featuring executives from the largest PBMs in the country.
PBMs, which serve as intermediaries between insurers and prescription drug plans, negotiate prices with pharmaceutical companies and determine the out-of-pocket expenses for patients. The three largest PBMs in the United States—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—control about 80% of the nation’s prescription drugs.
The committee’s findings indicate that these PBMs are promoting lists of preferred medications that tend to include more expensive brand-name drugs instead of cheaper alternatives. One example highlighted in the report is from Cigna, where internal communications discouraged using less costly substitutes for Humira, a treatment that costs around $90,000 annually, despite available biosimilars at about half that price.
Additionally, the report points out that Express Scripts informed patients they would incur higher costs if they chose to fill prescriptions at their local pharmacies instead of obtaining a three-month supply from its own mail-order service. This practice limits patient choice regarding where they can fill their prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) published its own report, noting that “increasing vertical integration and concentration” has allowed the six largest PBMs to manage nearly 95% of prescriptions in the U.S. This situation raises concerns as the leading PBMs wield significant influence over the accessibility and affordability of prescription medications for Americans. The FTC’s report suggests that vertically integrated PBMs may prioritize their affiliated businesses, potentially harming independent pharmacies and driving up drug costs.
FTC Chair Lina M. Khan stated that these practices result in patients being overcharged for cancer medications, generating additional revenues exceeding $1 billion for PBMs.