A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting their access to where these drugs can be obtained.
The investigation, which lasted 32 months, comes ahead of a hearing featuring executives from some of the nation’s largest PBMs. These third-party administrators handle prescription drug plans for health insurers and negotiate prices with pharmaceutical companies for medications, determining patients’ out-of-pocket costs.
The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control approximately 80% of prescriptions filled nationwide.
The committee’s findings indicate that PBMs have compiled lists of favored medications that prioritize higher-priced brand-name drugs over more affordable options. For example, emails from Cigna’s employees revealed that they discouraged the use of less expensive alternatives to Humira, a treatment for arthritis that was priced at $90,000 annually, even though a biosimilar was available at half the cost.
The report also highlights that Express Scripts informed patients they would incur higher costs for using local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service, thus limiting patient choices regarding their pharmacy options.
A similar report released earlier this month by the U.S. Federal Trade Commission (FTC) noted that increased vertical integration among PBMs has enabled the largest six to control nearly 95% of all prescriptions in the U.S. The FTC expressed concern, stating that leading PBMs possess considerable power over access to and affordability of prescription drugs for Americans. This arrangement fosters a scenario in which vertically integrated PBMs may favor their own affiliated companies, revealing potential conflicts of interest that can harm independent pharmacies and inflate drug costs.
FTC Chair Lina M. Khan remarked that the findings indicate these intermediaries are “overcharging patients for cancer drugs,” leading to more than $1 billion in additional revenue for them.