A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications and restricting their pharmacy choices.
The report, highlighted by the Wall Street Journal, stems from a 32-month investigation and prefaces an upcoming hearing featuring executives from the country’s leading PBMs. These entities act as intermediaries for health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket costs for patients.
The three dominant PBMs in the U.S.—Express Scripts, OptumRx, operated by UnitedHealth Group, and Caremark from CVS Health—control approximately 80% of all prescriptions filled in the country.
According to the committee’s findings, PBMs have developed preferred drug lists that often favor higher-priced brand-name medications instead of cheaper generic alternatives. The report references emails from Cigna officials which advised against using less expensive substitutes for Humira, a treatment for arthritis and autoimmune conditions that previously cost $90,000 annually, even though a biosimilar was available for around half that amount.
Additionally, Express Scripts informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through their affiliated mail-order service. This practice limits patients’ choices in selecting their pharmacies.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, revealing that the top six PBMs control nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern about the considerable power these leading PBMs hold over Americans’ access to affordable medication, suggesting that their practices could create conflicts of interest that disadvantage independent pharmacies and escalate drug prices.
FTC Chair Lina M. Khan emphasized that the findings indicate these intermediaries are significantly overcharging patients for cancer medications, generating additional revenue exceeding $1 billion.