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 access to lower-cost options. This report follows a lengthy 32-month investigation and precedes a hearing featuring executives from the largest PBMs in the country.
PBMs serve as intermediaries that administer prescription drug plans for insurance companies. They negotiate drug prices with pharmaceutical firms and determine patients’ out-of-pocket costs. The three dominant PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—control roughly 80% of prescriptions.
According to the findings, PBMs have established preferred drug lists that favor pricier brand-name medications over more affordable alternatives. The report highlights communications from Cigna staff that discouraged the use of lower-priced substitutes for Humira, a treatment costing around $90,000 annually, while at least one similar drug was available for half that price.
Moreover, the committee discovered that Express Scripts informed patients they would incur higher costs if they chose to fill prescriptions at their local pharmacies compared to their mail-order service, ultimately limiting patient pharmacy options.
In a related development, the U.S. Federal Trade Commission (FTC) issued a similar report earlier this month, indicating that the six largest PBMs manage nearly 95% of all U.S. prescriptions. The FTC expressed concern over the significant influence these PBMs wield over drug access and affordability. The report highlights an environment where PBMs can prioritize their own affiliated businesses, which may create conflicts of interest that disadvantage independent pharmacies and drive up drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen are charging patients excessive amounts for cancer treatments, generating additional revenue exceeding $1 billion.