A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are redirecting patients towards pricier medications and restricting their pharmacy options. This report follows a 32-month investigation as the committee prepares for a hearing involving executives from the largest PBMs in the country.
PBMs act as intermediaries for health insurers, managing prescription drug plans and negotiating prices with pharmaceutical companies. They also determine patient co-pays and out-of-pocket expenses. The three major PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of all prescriptions.
The committee’s findings indicate that PBMs prioritize more expensive branded drugs over more affordable alternatives. For instance, emails from Cigna employees discouraged patients from using cheaper substitutes for Humira, an arthritis treatment priced at $90,000 annually, even though a biosimilar option was available for half that cost.
Additionally, Express Scripts informed patients that filling prescriptions at local pharmacies would incur higher costs compared to obtaining a three-month supply through their mail-order pharmacy service. This practice limits patients’ choices in selecting their pharmacies.
Earlier this month, the Federal Trade Commission (FTC) released a similar report, noting that increased consolidation among PBMs now allows the six largest firms to handle nearly 95% of prescriptions in the U.S. The FTC expressed concern that these developments grant significant power to PBMs over patients’ access to affordable medications. They highlighted the conflicts of interest that arise when vertically integrated PBMs favor their own affiliated businesses, potentially disadvantaging independent pharmacies and inflating drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen are “overcharging patients for cancer drugs,” generating additional revenues exceeding $1 billion.